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Commentary
How Biden can keep millions of Americans from losing health insurance
If the United States guaranteed health insurance to everyone, 212,000 people who died from COVID-19 in 2020 might still be drawing breath. So calculates a new study from Yale and the University of Massachusetts, and like all counterfactuals, the researchers’ number mixes in a little art with its science. (For one thing, even universal insurance wouldn’t have saved those who killed themselves by anti-vaxxing.)
What’s indisputable is the long line of corroborating research that universal insurance would save lives. Many uninsured Americans put off vital care for fear of the cost, a decision that’s contraindicated if healthy longevity is what you seek. If you think that these preventable deaths, and the medical bankruptcies that uninsurance helps fuel, are a national shame, fasten your conscience’s seatbelt. They’re about to get worse, as between 8 million and 17 million Americans plunge off a looming “insurance cliff.”
These people aren’t lemmings, which in popular mythology march off precipices under their own self-destructive power. Rather, they’re getting a rude shove off this cliff by three political decisions. First, expanded Obamacare subsidies for coverage, part of the American Rescue Plan, lapse at year’s end. Second, expanded coverage by Medicaid, the state-federal program for the poor, will terminate when the Biden administration declares an official end to the COVID health emergency. (The betting is that the president will keep his hands off that hot potato until after November’s midterms. But he’ll have to seize it at some point.)
[T]he president needs to think bigger.
The third reason is one for which Biden has only himself to blame. He put off the more fundamental health reform on which he campaigned — and even that plan likely wouldn’t be enough dynamite to permanently level the insurance cliff. Commendably, he’s working on short-term detours away from the cliff. But the president needs to think bigger.
He ran on a public option — a government-run, alternative plan to private insurance. It would pay doctors and hospitals less than private insurance but require them to take its enrollees; that would trigger demands that caregivers lower their charges to private insurers, so that the latter could compete for customers with the public option. It’s a potent strategy for controlling out-of-control health costs.
But by itself, a public option wouldn’t get us to universal insurance. Indeed, some analysts predict it would increase the numbers of insured only marginally, luring customers away from private plans while extending coverage to very few uninsured.
In fairness, Biden has a heart, unlike President Tin Man before him. Obamacare enrollments fell in each of Donald Trump’s four years in office, as the then-president led a Republican jihad that weakened the law even as it failed to kill it. Biden has reversed the downward trend.
[L]ike the tax collector and the funeral director, the shortcomings of America’s patchwork health insurance can’t be dodged forever.
But if the Congressional Budget Office is right, once the American Rescue Plan subsidies disappear, enrollments could fall to what they were in Trump’s last year. While Biden hoped to preserve the subsidies in the Build Back Better-on-a-diet plan he’s negotiating with Joe Manchin, they may be sacrificed on the altar of government economizing.
The administration has thrown carrots and sticks at states to keep people covered after it declares the COVID emergency over. Still, like the tax collector and the funeral director, the shortcomings of America’s patchwork health insurance can’t be dodged forever.
There’s a way out for Biden. First, admit the public option can’t do the trick. Second, embrace the solid ideas of revenue-raising tax simplification and prudent budget cuts. Third, devote some of that new money to Obamacare for All: universal, affordable, mostly private health insurance. Germany, the Netherlands and Switzerland offer models. (The New York Times had fun with a March Madness-type competition among national health care systems, asking five experts to pick the best. Germany and Switzerland came out tops.)
There’s no shame in Biden copping to the timidity of his campaign idea. His old boss disdained mandatory insurance, except for children, when he first ran in 2008. Once in office, Barack Obama realized a requirement applying to everyone was essential to keep coverage affordable. Voila — we got Obamacare, with an individual mandate upheld by the Supreme Court. The country’s uninsured hit a record low.
As always, the road to progress is blocked by political bickering. Progressive Democrats can’t contain their dog-chasing-cars pursuit of Medicare for All, even though Democratic primary voters in 2020 said no to its price tag and abolition of private insurance. Biden meanwhile didn’t prioritize health care reform in his original Build Back Better; Manchin worries about deficit-cutting.
A holistic approach — tax and spending reforms, plus government-subsidized-and-regulated private insurance — could deliver liberals’ dream of universal coverage, while averting moderates’ nightmare of Uncle Sam running bake sales to pay his deficits. Who knows — it might also attract some of Congress’s few, sane Republicans.
As for average Americans, they keep dying or going broke from medical bills. Meanwhile, the parade to the insurance cliff marches on.
