Dear Mr. President-elect:
Your position on universal health insurance has been admirably clear. You support it. You did before you ran for president and continued to do so in the campaign.
In 2000, you wrote, “We must have universal health care.” In a Fox News debate last year, you said, “We have to take care of the people that can’t take care of themselves.” On “60 Minutes,” you said, “Everybody’s got to be covered.”
I am writing to you now because I am concerned that Republicans in Congress do not share your goal and are not giving you good advice on this issue. I’m worried that they are not acting in the best interests of your presidency or the country. I encourage you to be skeptical of them.
It is entirely possible for you to sign a conservative health care bill that lives up to your belief in universal coverage. It’s a bill that you could celebrate as a replacement of Obamacare. But it would be quite different from the bills that congressional Republicans are pushing.
When they claim that their bills will not take health insurance away from millions of people, they’re engaging in magical thinking. They are trying to fool the media, voters and you.
They are focusing on a strategy of “repeal and delay,” in which major parts of Obamacare will remain for months or years. In the intervening time, they say, they will somehow keep people from losing insurance.
But they do not have a realistic plan, despite years of talk. Nor, to be blunt, does your choice for secretary of health and human services, who is one of those congressional Republicans. And a repeal is likely to undermine insurance markets long before its effective date.
Mr. President-elect, you are a businessman. You understand that savvy executives don’t simply live in the present. They look to the future. They’re fond of quoting Wayne Gretzky: “Skate to where the puck is going, not where it has been.”
Insurance executives can see through the magical thinking of politicians. They know that a functioning insurance market must include both healthy and sick people. There are very few ways to guarantee this combination. Without Obamacare’s subsidies to help people buy coverage and its mandate (weak as it is) to require they have coverage, markets will break down. The healthy will leave, the sick will stay and costs will soar.
After a repeal is signed, the uncertainty will give insurers reason to exit quickly. As Nicholas Bagley, a leading expert at the University of Michigan, says, “If you’re an insurer, you’re likely to head for the hills.”
The chaos runs a high risk of leaving millions of people without insurance early in your presidency. Many of them will be members of the white working class who voted for you. Everyone who loses insurance will be grist for criticism of you.
As you know, the Republican leaders in Congress have never been your biggest fans. I think it’s fair to say that they care more about being able to brag that they got rid of Obamacare than about your political standing. The bills they are considering threaten your standing.
But you have alternatives.
The crucial first step is to avoid repealing the insurance expansion without simultaneously replacing it. The new Congress comes to Washington next week, and its members should know where you stand from the beginning. It won’t work to promise millions of people health insurance on spec.
If you avoid this trap, you can then push both parties toward a different version of universal health coverage.
“There is a ton of policy space for compromise,” as Bagley says. “There is room for a really interesting discussion and potentially a breakthrough that could rebrand Obamacare and replace some of the portions of it that most set Republican teeth on edge.” You will like this, Mr. President-elect: Bagley also says you are “the kind of politician who could cut a really interesting deal.”
That deal could give states more flexibility to meet the top-line coverage goals. It could rely more heavily on subsidies to bring healthy people into the market – and ultimately scrap the mandate. It could permit insurers to charge young people less (and older people more). It could create incentives for personal responsibility, allowing higher prices for people who have voluntarily gone without insurance.
I will be honest that I do not favor some of these ideas and worry that they would cause hardships. But I was not elected president, and you were. And all of these ideas are within the realm of serious debate about our health care system.
For your sake and the country’s, I hope you insist that Congress deals in reality. Magical thinking isn’t good for a presidency.
The writer is a columnist for The New York Times.