When it comes to health care, President-elect Donald Trump made it clear that he’s all in favor of dessert but doesn’t want any Brussels sprouts.
He said in an interview with the Wall Street Journal that he’s not against all aspects of Obamacare. He’s in favor of the ban on insurers denying coverage to people with pre-existing conditions, and he supports keeping kids on family policies until they turn 26.
“I like those very much,” Trump said.
Well, yeah, those are among the provisions that everyone likes. Polls consistently show that to be the case.
The trouble is, in the real world, you don’t get dessert unless you finish your veggies.
At issue is what’s known as guaranteed issue – the idea that health insurance is available to all, regardless of medical condition.
The thing to keep in mind is that guaranteed issue means an insurer has to cover more sick people, and they’re expensive. Sick people submit claims that have to be paid.
To balance that out and keep coverage affordable, insurers need more young and healthy people paying premiums. That’s what Obamacare accomplished with its mandate that most people who don’t receive insurance from an employer buy coverage through a state exchange.
Here’s where reality intrudes on Trump’s fantasy.
Even though he said in February at a town hall in South Carolina that he likes Obamacare’s mandate, it doesn’t seem like the idea remains a part of his thinking. He’s said far more frequently that he views the health care reform law as a “catastrophe” and a “disaster.”
Moreover, there isn’t a single prominent Republican in Congress who supports the mandate.
That’s a problem.
“If they don’t have a mandate, the whole thing unravels,” said Alain Enthoven, a Stanford University health economist. “You need a way to get young, healthy people into the program.”
This is how single-payer systems in other developed countries work. Using taxes instead of premiums and copays, they include everyone in the risk pool, sick and healthy, young and old. That spreads the insurance risk throughout the entire population and keeps costs down for all.
This is one reason that the average citizen of the European Union pays $3,600 a year for health care. The average American pays $9,400.
Unless Trump plans on nationalizing private insurers – and thus creating an American single-payer system – there’s not much he can do to force private insurers to play ball. These are primarily for-profit companies, and they’re not in the business of losing money.
No insurer would agree to guaranteed issue without a mechanism in place to expand their coverage of the young and healthy. Even if the Republican-controlled Congress passed a law forcing them to do so, which would never happen, insurers would simply raise rates to the point where no one could afford policies.
“If the Republicans succeed in repealing the Affordable Care Act, it will cause many tons of hurt to a huge number of people,” said Ron Pollack, executive director of the advocacy group Families USA. “We are looking at a giant step backward.”
So it’s nice that the president-elect likes the popular parts of Obamacare.
If he wants to keep guaranteed issue, though, he’ll also have to embrace one of the least-popular parts – the mandate.
Or he could surprise us and endorse a Medicare-for-all system.
But that too is a fantasy.
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