The rubber has finally hit the road with the introduction of the Senate Republican attempt to repeal and replace Obamacare. The action has strained the fragile links that hold the Republican Party together. Healthcare is a confluence of controversies, unadulterated politics, societal values, money - not to mention that it is the central caring service of society. The solution to the delivery of healthcare has challenged the unique blend of free market and liberal culture of America for decades. Once again it has presented itself for a conclusive fix in the Senate of the United States of America.
For the moment the Republican Establishment’s effort to assert the traditional Republican principles of “small government” and “market forces to regulate prices rather than deliver services by entitlements” has been stalled. Ironically, these are no longer the central tenets of the Republican base, certainly not of those of the Trump voters. What has happened and what is happening in the GOP Caucus, behind closed doors, is the battle for the heart and soul of the Republican Party.
THE REPUBLICAN MOVERS AND SHAKERS
The central dramatis personae in this current denouement are all Republicans - President Trump, Mitch McConnell, Senate leader and Paul Ryan, the Speaker of the House of Representatives. All of them share, for a host of reasons, only one overriding objective - repeal and replace Obamacare. The chief political motivation is to rid the American scene of anything Obama. It has become patently obvious that the mantra relating to Obamacare is not backed by any workable solution to the problem that eats up one in every six dollars in the American economy.
Ryan represents the purist philosophy of a conservative fiscal market based economy which simplistically maintains that healthcare is not a right and how much it costs is predominately a function of market forces. The President has staked, for what it is worth, a position that is at variance with Republican fiscal conservatism. He punted again and again on the campaign trail that he, “unlike other Republican candidates”, regarded Medicaid, Medicare and Social Security as sacred. Again and again Trump, reading the Republican base better than the professionals and promised health care for all at lower cost. He has attacked Paul Ryan’s bill on Trumpcare as “mean”. (However, to put it kindly the POTUS is not reliable and will declare victory if the Republicans present him with any bill to sign into law that rids the country of the “disastrous Obamacare”). McConnell, a highly skilled politician, has the burden to deliver for the purist Republican philosophy. He has the arduous task of melding the disparate factions of the Republic Party which are represented by Rand Paul, who believes any government intervention in anything is evil and the moderate Susan Collins. Mercifully in the Senate there are a number of Republicans who oppose placing health care of the whole population to the mercies of the market place. While fortuitously for the Democrats they join the purist Paul faction who argue that McConnell’s version of Trumpcare is not pure enough, thereby making the objective of fifty votes an impossible challenge. For the Republican traditionalists there is the reality of the revolt amongst the body politic, including Republicans, who want their healthcare.
HEALTHCARE: SOCIETAL SERVICE VS MARKET
The noble profession of ministering to the sick and the vulnerable swallows up three trillion of the eighteen trillion dollars spent in the USA. The dilemma uniquely facing the United States of America is that while it spends more, by far, than any other nation in the world on health, it falls far short of providing care for all its citizens. Even more galling is the fact that their health care parameters such as neonatal mortality and longevity are way behind nations who spend a fraction on medical services. While it is fair to say that America is in the forefront of medical innovation the high cost renders the advances inaccessible to many.
Putting this matter in an economic/political context, America is wrestling with the problem of providing a solution to an essential benefit via the market place. Nothing more has epitomized the incongruity between the market economy and caring for society than the fact that the commonest reason for bankruptcy in America is failure to pay medical bills. While Obamacare made a sizable dent in the coverage of citizens bereft of medical coverage it didn’t comprehensively address all the financial and many other problems that beset the endeavor of caring for the nation’s people. Even with Obamacare, copays and high payments before insurance kicks in are a central concern of a small section of the electorate.
So with an aging population, the humongous cost of health care as compared to other Western nations and the advances in medicine the American Congress once again takes up the issue.
STATUS QUO
While Obamacare has its problems and its introduction was unpopular it has after nearly seven years taken hold. These problems have been exacerbated by the uncertainty of the future. Insurance companies are loathe to put out programs if there is doubt if they will be funded. Trump particularly has dwelt on this fact shouting from the rooftops that Obamacare has failed. He conveniently ignores the fact that he more than anyone else is flaming the fires of its destruction. The POTUS believes that if Obamacare collapses with his help, the body politic will blame Obama rather than the Republicans who control Congress and the Presidency for their lack of health care. McConnell knows better - Obama is in Indonesia and Trump is in the WhiteHouse.
There is overwhelming support for Obama’s Affordable Health Care Act at the moment. Polls show that over sixty percent favour its retention and less than forty percent support its repeal. Other public assessments show that Obamacare is favored over Trumpcare by two to one. In fact in several constituencies the Republicans were hammered at Town Halls for their support of repeal and replace Obamacare. In fact the latest survey shows only a seventeen percent support for McConnell’s version of Trumpcare.
Over twenty million more Americans are said to now have medical insurance and no -one can be denied coverage on the basis of pre existing conditions. Obamacare has resulted in the expansion of Medicaid which now serves seventy -five million souls. Half the births in the USA are covered by that agency while the elderly account for forty percent of its funds as it covers nursing home care for the indigent. This is what the Republicans are threatening to disrupt. The new Trumpcare will by contrast deprive twenty two million citizens of medical care.
Obama’s legislation was funded to a large extent by a tax on the top one percent of earners in the USA. Crucial to Trump’s new tax plan is that he needs to release that money. The reason for the urgency of repealing and replacing Obamacare is to make his tax plan viable. It is not for nothing that the central thrust of the Democratic attack is that the Republicans want to take away health care from the poor in order to deliver a tax break for the rich.
WHAT NOW?
- It ain’t ever over till the fat lady sings and McConnell will do all in his power to try and get the fifty votes needed to pass his bill. It is a heavy scene as nine of his caucus have publicly announced that they are against Trumpcare. The reports are that the number that would have voted against the bill had it come to the floor would have been far higher. According to the Washington Post only sixteen of the fifty- two Republicans were thought to be leaning to vote for the Bill. In fact only six Republican Senators publicly committed to vote pro. None of this will deter McConnell from trying.
* It is interesting to note that the moderates are not appealing to the President who is ostensibly on their side to save his bill. Rather from Lindsey Graham, to John McCain and Susan Collins there is a call for cooperation with the Democrats to pass a healthcare bill.
* If all else fails the Republicans it would be prudent for them to reassure the jittery insurance companies and see to it that Obamacare doesn’t collapse thereby throwing the care of Americans into crisis mode.
* The key Republican financial backers lead by the Koch brothers are still committed to purist Republican principles. At a gathering this last weekend, attended by the true believers such as Ted Cruz, the brothers resolved to punish those Republicans who did not back axing Obamacare. They have endless sums of money and were floating spending four hundred million dollars on Republican Primaries and the 2018 midterm elections.
* At the end of the day the Health Care issue has resulted in the Republican Party splintering into factions. There are the traditional purists and then there are those who are modifying the traditional exclusive market approach to deal with all issues. For years there have been modifications to this approach. For a large part of the twentieth century, when the capitalist approach did not concentrate all the resources into the one percenters there was enough to go around for a large middle class to cope. This especially so as the population was younger and their employers, by and large subsidized their health care.
* Wealth is now concentrated in the one percenters, the middle class has shrunk and a far greater section of the aging society needs social welfare. In short the contract that the employers had with the workers which made American capitalism beneficial for the whole society is broken. Business which used to take its social responsibility seriously has abandoned this role for pure profit. In addition far fewer of the population have jobs that afford them medical coverage. (Robert Reich in his latest book “Saving Capitalism” has clearly documented this process.)
Society has moved to a consensus that wasn't even evident in the Clinton Presidency thirty years ago. It is now accepted that all citizens are entitled to health care and this is a responsibility of government. Trump connected with that consciousness and that was one of the reasons that he won the Republican nomination and then the Presidency. (Not that Trump really gives a hoot as to what appears in the final Bill as long as it gets rid of the “disastrous Obamacare”).
Any of the needed paradigm changes to the profitable health care industry requires a bipartisan effort to disrupt the stranglehold that that industry enjoys over Congress. The industry employs 2354 lobbyists - over five for each member of the legislature. The bill spent for the lobbying endeavor, according to the Center for Responsive Politics, is over a one hundred and fifty million dollars per annum. Only one of the constituencies that make up this cabal is now four square behind reform and that is the medical profession. The latter, particularly the American Medical Association, have abandoned their trade union protectionist role, serving only their members, in the interests of equity.
AT THE END OF THE DAY
* All this begs the fact that the delivery and the business of medicine is still based on market economy principles. The cost to the consumer is far higher than any other country. What health care executives earn even in local operations, whether they are hospital CEOS or Pharmaceutical Executives is obscene. America spends three trillion dollars a year on health care of which nearly a trillion goes to the administration of the endeavor. A paradigm change is needed in the education of health care professionals, the administration of health care including the introduction of a single payor system, the legal system that dictates that doctors practice costly medicine to avoid litigation and in the regulations that govern the heath care endeavor.
* Between Trump and Healthcare this may be the beginning of the split of the Republican Party. The 2018 midterm elections may force the Republican Party to splinter and as matters stand the GOP are heading for a beating.
* There will have to be a bipartisan solution to this crisis. This is most likely to occur after the 2018 elections.
* Historians will reflect how on earth a society which thrives on competition and the “free market” afforded one commodity, healthcare, a virtual monopoly and sat and watched while costs and profits soared while the country’s citizens suffered.
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