Like many and probably most, I am concerned that the healthcare ‘sausage’ produced by the secretive machinations of the Republican Congressional butcher shop might be bad for our health. Like many, my dissatisfaction with both the process and the results prompts me to object. I join in protesting individual aspects of the measure. Included, by way of example only, are the likely loss of insurance by some 20+ million folks, the watering down of Medicaid benefits, including nursing home care for millions who have exhausted their resources, with the almost trillion dollars so saved providing tax breaks to the wealthiest who don’t need them.

But I also want to challenge what I see as fundamental flaws in the choice of ingredients – basic design flaws. And also point to the little talked of proposal that would more likely provide optimum insurance coverage versus cost. These points will be taken in inverse order.

Any sensible discussion of healthcare insurance must be based upon an understanding of how insurance works. To arrive there, the following questions should be asked: To be successful, must not an insurance plan be able to spread the risk among many, so that only a relatively few will make claims during a given period ? In turn, is it not true that the larger the risk pool, the lower the premiums charged to those protected? Not even the most right wing Republicans are likely to dispute these propositions. Once acknowledged, if brought into the analysis, the most advantageous combination of coverage and price becomes apparent.

Our nation’s entire populace not already served with health insurance is a ready made, gigantic health insurance risk pool. Maintaining it intact and insuring its members through a single federally operated program would be the ideal solution. And a working model already exists: Medicare. Expanding that program to include the Obamacare / Trumpcare members would be quite doable. The addition of this enormous group would infuse the mostly post-65 Medicare congregation with much younger, less claim-prone participants. It would produce the additional, badly needed bonus of shoring up this vital program. A simple and elegant solution to two vexing problems..

However, the Republicans are following the fragmented, state-by-state, Obamacare format as the basis for their program to replace it. The immense, unified national risk pool is thus divided into 50 smaller pools. And they continue down the Obamacare path in breaking up each of the 50 ‘fragments’ by allowing as many insurance companies as are interested – each their own separate risk pool – to ‘compete’ for the business of each individual resident

Two stark departures from the Obamacare pattern further dilute the risk pool.

First, each citizen is authorized to decline to participate, without the Obamacare penalty that had moderated defections.

Next, each state is empowered to allow each insurance company to offer varying levels and types of coverage. This feature is heralded as “freedom to choose the coverage that suits [ones] needs”. Never mind the reality that none of us can foresee the future maladies or injuries for which we will need treatment. Presumably, policies providing more modest coverage would bear more modest premiums. These would appeal to persons who perceive themselves to be healthy and fail to appreciate that they are not immune from costly medical problems – particularly the young. Older folks, who realize they face a wider range of health threats, would need the more expensive broad coverage. In this fashion, the risk pool is further splintered. And, principally on the basis of age.

In so deconstructing the huge segment of society that needs healthcare protection into the young and the old, the Republicans treat us as members of separate categories. In fact we belong to one class, but are participants in a continuum, in a process – aging, growing old. Assuming a normal life span, each of us will be both young and old. Each will participate in the general benefits and burdens of each stage of the process. Any perceived disadvantage to younger persons by placement in the same risk pool as the elderly
is self-correcting as we age. The Republican party has gone out of its way to disadvantage those of us in the later, more expensive stage, when so many have so little ability to cope.

Whatever else, the Republican Congress has not set out to provide healthcare, as and when needed, for everyone, and at the most advantageous price. Conservative orthodoxy has gotten in the way of their ability to do the right thing about healthcare. It has de-sensitized the members to the needs of ordinary folks. It has relaxed their intellects so as to accept contorted theories and overrule rational, experience-proven understandings of how insurance works.
Whether the Republican Congress can succeed in throwing so many of us under the healthcare bus, or other sensible and beneficent forces prevail, will go a long way in revealing whether we actually have a government that is, in President Lincoln’s words, “of the people, by the people, for the people”.

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