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How we got here on health insurance

Before we all dive into the details of the long-awaited Senate Republican proposal to overhaul the Affordable Care Act (ACA), better known as “Obamacare,” let’s take care of one important piece of related business.

The backdrop to this proposal, of course, is the GOP’s full-throated assertion that Obamacare is imploding, falling of its own weight, nearing collapse (choose your imagery). Evidence for this claim is the growing number of insurers who are dropping off the health insurance exchanges in many states and the steep rise in premiums remaining insurers are seeking.

When the ACA was passed, one of its foundational principles was a simple one: In exchange for being legally required to offer robust policies (the kind that covered obstetrician services, rehabilitation services – you know, all the things that consumers actually need) and to end the shell-game of pre-existing condition exclusions, insurers would have a vastly expanded pool of people buying insurance. How would that pool be expanded? Two ways: Subsidies would be provided to lower-income people who needed help and all adults would be required to have health insurance.

There was, and is still, a debate over whether health insurance should be added to driver’s insurance and Social Security/Medicare as areas in which Americans should be compelled to pay for a benefit on the grounds that it is not only an individually good thing but something that accrues to the benefit of our whole society. Still, the bottom line was that for Obamacare to work, this foundational transaction had to take place.

Along comes President Donald Trump. On Jan. 20, the day he is sworn into office, he issues the first of what has proven to be a long series of executive orders. This one directs all agencies of the federal government to “waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.”

The IRS interpreted this as an order not to require taxpayers to provide proof that they have health insurance. This was to be the first year when the compulsory requirement was to be aggressively enforced. No longer.

CareFirst CEO Chet Burrell cut through all of the political blather when he was asked recently what it would take to make Obamacare work. It’s simple, he said. Enforce the individual mandate, which would result in a broader pool of insurance consumers that included younger and healthier customers – the sort of pool that would bring down costs and premiums.

Other insurance company executives made it clear that another Trump administration decision – to waffle on whether to approve the ACA’s cost-sharing subsidies for insurers – further added jitters to the private insurance marketplaces.

Obamacare is hardly perfect, and its creators have acknowledged there would be a need for fixes, corrections and adjustments. Lest anyone forget, the Social Security Act was enacted in 1935 and substantially amended in 1939. And in 1946. And 1950, 1954, 1972, 1977, 1980, 1983 and so on. Some of these changes were technical, others were major alterations, a few substantial expansions. The point is that sweeping social legislation never emerges in a perfect or unalterable form. There should never have been any illusion that Obamacare was the end of health insurance or health care reform.

As Republicans flail around with a replacement for Obamacare, which, with the exception of the Medicare expansion always was an essentially Republican policy idea, Democrats have enjoyed their predicament. That does not accrue to their honor. Party leaders believe there are ways to fix the law short of what Republicans have proposed; after all, the party’s presidential candidate Hillary Clinton campaigned on a set of proposals she said would cure the law’s defects. They have not chosen to offer them to the public.

Many Democrats believe that enforcing the individual mandate and meeting the cost-sharing subsidies by themselves would solidify the law. If they believe that – and the individual mandate is probably the most unpopular feature of Obamacare — they should have marched straight to the nearest federal courthouse and sued the Trump administration for not requiring the IRS to enforce the law. Republicans have shown no shyness about using the courts, as they have every right to do, to address the grievances they had about the ACA.

Believe it or not, there was actually an instance in which Democrats and Republicans agreed on a legislative fix to Obamacare – and passed it. Together! In April of 2011, President Barack Obama signed into law a bill that eliminated an ACA provision that had required small businesses to file a document with the IRS for any expenditure more than $600. It was a stupid rule and had led business owners to complain, justifiably, that this would be a paperwork nightmare. Members of both parties agreed: 238 Republicans and 76 Democrats in the House voted to end the regulation. The Senate margin of 87-12 was even more bipartisan.

My, weren’t those the days.