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Democrats are expected to vote early next week on a bill, H.R. 1425, entitled the “Patient Protection and Affordable Care Enhancement Act.” The bill is exactly what it explicitly claims to be - a doubling down on the original structure of ObamaCare, with some extra patches added in. This is likely a foreshadowing of the push we’ll see to take the next step in expanding government control of health care should Democrats succeed in taking the White House in 2020.
ObamaCare, as we’ve often pointed out, was at its core an exercise in massive centralization, aiming to force as much of the private market in health care payments into a top-down framework as possible. We’ve all seen how that has worked out. Although of course a slice of the population did benefit from forcing insurance companies to offer uniform benefits and to have to cover all pre-existing conditions, insurance premiums on the individual market rose sharply, as did deductibles and out-of-pocket maximums, ultimately diminishing the quality of health care for all.
Many individuals who don’t have the option of employer-sponsored care rationally made a cost/benefit analysis that led millions of (mostly younger) Americans to conclude they were financially better off still going uninsured - even before ObamaCare’s individual mandate penalty was taken out of the picture by the Tax Cuts and Jobs Act in 2017. The whole premise of ObamaCare was to force these younger people to buy in, in order to subsidize, and thus make cheaper, insurance for older, sicker patients. Their refusal to do so was predicted by free-market economists a decade ago.
Meanwhile, the rise of the gig economy and self-employed contractors has continued to increase the number of individuals ineligible for traditional employer-based insurance - a problem currently massively exacerbated by mass unemployment in the wake of the COVID-19 lockdowns. With Congress unable to do better than failing to pass a bill that amounted to ObamaCare-lite in 2016, the Trump Administration, to its credit, has attempted to provide individuals with as many new coverage choices as it can without new legislation.
The administration expanded state waivers under Section 1332 of ObamaCare to let a greater variety of insurance coverage options to be offered on the health insurance exchanges. The administration also allowed for the issuance of short-term, limited-duration insurance plans to fill in as a lower-cost stopgap option for those who don’t want to (or can’t) pay for a full insurance plan. Most importantly, the administration allowed for the creation of association health plans, which allow groups of individuals to band together to purchase health insurance outside of many of ObamaCare’s restrictions on the individual market. Naturally, Title I of H.R. 1425 specifically rescinds all three of these options.
Instead, the bill increases insurance premium subsidies for individuals who buy plans through the exchanges, expands who is eligible for the subsidies, and provides extra funding to try to get states to figure out innovative new ways to push people to purchase the now-theoretically-cheaper plans in the exchanges. Title II of the bill then creates major financial penalties for states which haven’t passed the Medicaid expansion (which were initially mandatory until the Supreme Court found that unconstitutional and re-wrote the law to make it voluntary, if you’ll recall). It then expands Medicaid eligibility and benefits and places centralized price controls on prescription drugs for good measure.
Democrats clearly want to send the message that they think ObamaCare can work as long as they take away all your other choices and throw enough money at it. There is little evidence that forcing more people into Medicaid and the exchanges will improve the quality or costs of our health care system, but the more of the population that is funneled into these systems, the easier it will be for progressives to build towards their ultimate goal: Medicare for All.
It is more crucial than ever that Republicans counter with a clear embrace of the power of free people to make better decisions for themselves, to unleash innovation and the power of competition. Doing so will take the humility to admit that government lacks the knowledge necessary to create a system that will work for everyone from the top down.