Ashish Jha explains why the “ABCs: Arithmetic, Bravery, and Competence” are so important for reforming the US healthcare system.
As President Obama found out in 2009 and 2010, reforming the US healthcare system is hard work. Our system has some stubborn problems that are difficult to address. There are strong vested interests whose preferred solution is often the status quo. And, because of the complexity of the system, reforming any one part can have large, unintended consequences on other parts in ways that undermine the broader effort. This is why, if you are a political leader who wishes to reform the system, you need to pay attention to the ABCs: Arithmetic, Bravery, and Competence. And it is through this lens that we can understand how, in 2010, President Obama and the Democrats were able to enact the Affordable Care Act. And it is this lens that provides a clearer understanding of why President Trump and the Republicans failed so badly.
The ABC lens of healthcare reform
The most difficult part of getting to universal coverage in the US is the arithmetic. Providing healthcare coverage for healthy people is easy: they are cheap. And people over 65 or those who are quite poor are already eligible for government insurance, which leaves one group out: Americans without employer-sponsored insurance who are either older (typically 50 to 64) or have a chronic disease. Few of these individuals are able to afford private insurance on their own, primarily because insurance for them is expensive. And any reform plan that tries to cover them has to deal with that math. Obamacare covered these individuals by putting them into insurance pools with young (healthy) people (who cross-subsidized their older, sicker compatriots) and provided generous subsidies to help defray the costs. The Republican plan was the opposite: they eliminated the individual requirement for insurance (which would dramatically reduce the number of young, healthy people in insurance pools) and cut subsidies. The result: the arithmetic just didn’t work and the non-partisan Congressional Budget Office estimated that 24 million individuals would lose their health insurance under the Republican plan.
The second essential element of healthcare reform is bravery. Any efforts to reform the healthcare system will upset vested interests and our $3 trillion industry has many of them. Tackling that requires political bravery. When the Democrats began working on Obamacare, strong vested interests initially lined up against key provisions of the bill. Instead of backing down, the Democrats got to work, ultimately winning over powerful interests like the insurance and hospital industries. The Republicans failed the bravery test in two ways: first, while they espoused a belief in market-based reforms, their plan failed to create one. And, when major groups lined up against the Republican plan, they quickly folded—lacking the bravery to fight. Obamacare took over a year of cajoling, lobbying, and fighting before it finally passed. The Republicans gave up less than three weeks after introducing their bill.
The third essential element of healthcare reform is competence. Because the US system is so very complex, reforming the system requires real expertise. Thankfully, both political parties have experts who are capable of helping. When the Democrats began to craft the bill that would eventually become Obamacare, they brought in their best experts, who used advanced analytics and sophisticated models to assess the likely impact of their reforms. While Obamacare was hardly perfect, it was rational, and coherently crafted to achieve the goals of its architects. The Republican bill was not. The GOP (“Grand Old Party”—a nickname for the Republicans) failed to engage most of their own experts and instead, created a bill that was poorly designed and would be unlikely to meet the Republican policy goals of a more efficient, market-based system. In the end, the poorly designed bill had no natural constituents who were willing to champion it and the bill died even before a vote was taken.
We are now at a cross-road. Having failed to repeal or reform the Affordable Care Act (i.e. Obamacare), some Republicans are ready to move on to other topics. But healthcare isn’t going away from the political spotlight for several reasons. First, for more than 7 years, the Republicans have campaigned on repealing Obamacare and large numbers of Republican supporters are unlikely to be satisfied with a short, 3-week effort that produced nothing. We can expect to see efforts to revive the Republican plans, either by reviving other existing bills (such as Cassidy-Collins, which lets states decided what kind of healthcare reform they want) or tinkering again with their failed efforts to garner enough votes.
Whatever happens next, Obamacare remains the law of the land and is now being managed by President Trump. Under President Obama, the ACA was run by competent, effective people who believed deeply in its underlying goal—using the power of the government to increase access to care. Even under those circumstances, the ACA struggled to always function effectively. It is now about to be managed by an administration that does not believe in its basic goals. How well the ACA will do in the upcoming years is unclear.
Politically, the fight that is shaping up is that if the Administration fails to manage the ACA effectively, and health insurance markets fail, President Trump will try to blame the Democrats. Many experts believe that the current President will get the blame for the failures of the market that happen on his watch. The truth is that if the ACA health insurance markets perform poorly in the upcoming years, it is unclear who will be the political winner. What is certain is that the millions of people who rely on those exchanges to get their insurance will be the losers.
Ashish K. Jha is the K. T. Li Professor of Health Policy at the Harvard T.H. Chan School of Public Health, Professor of Medicine at Harvard Medical School, and Director of the Harvard Global Health Institute. He practices Internal Medicine at the V.A. Boston Healthcare System. His major research interests lie in improving healthcare delivery systems, both in the US and globally and how to use policies, data, and technology to make care safer, more effective, and more efficient.