The Congressional Budget Office estimates that if the existing GOP health care bill becomes law, 24 million fewer people will have health insurance in 2026 than if the Affordable Care Act were to remain in place. This makes sense, of course, if for no other reason than uninsured people would no longer be criminals (sorry, tax evaders) – a powerful incentive to be insured.
But The New York Times points out something interesting. The figure of 24 million is actually 1 million more future uninsured than if the ACA were simply repealed as promised, returning federal health care regulation to what it was in 2010.
It’s not as if the status quo in 2010 was exactly healthy, so to speak. Among other problems, the unfair tax treatment of personally paid policies and lack of competition across state lines supplied inflationary pressures then as they do now. Rather than addressing these, however, the ACA layered on an entirely new set of undesirable features. Now, in addition to all the preexisting distortions in the health insurance market, the ACA:
- Mandates coverages (contraception, for example) that not everyone wants or needs, making premiums higher for everyone
- Requires first-dollar coverage of routine/preventative care, insulating providers from market competition
- Fines (sorry, taxes) consumers for choosing not to buy a product
Never mind other issues, like driving competitors from the market and the whole “if you like your doctor, you can keep your doctor” fiasco. It really is remarkable that congressional Republicans are unwilling to make the case that 2010 is a better starting point for meaningful reform than 2017 – especially since they promised a “repeal.”
But there is something else going on here as well, something that is probably too far downstream to be pulled back up. The entire debate about health care has gotten shoeboxed into language about health insurance. Under the de facto terms of this debate, More Insurance (whether defined as “more things covered by the policy” or “more people with a policy”) = Better Health Care. But this is a false equivalence.
For example, the Washington Post reported in December that life expectancy actually declined in 2015, for the first time since 1993. And this at a time when the uninsured rate was plummeting, thanks to the ACA’s mandate (sorry, tax).
Now it may not be fair to blame the ACA for literally causing more deaths. But the point remains that the relationship between health insurance and health outcomes is far more complex than a simple linear correlation. Walking the path to true, meaningful reform that improves outcomes means challenging the very terms of the political debate. Unfortunately, this is looking increasingly unlikely.