What a shock. It looks like the Better Care Reconciliation Act, or BCRA, is about to be buried, along with the AHCA. Senator Mike Lee was signalling skepticism, and he has now come out against it. And so has Senatory Jerry Moran of Kansas. Both GOP of course. What Moran said was interesting:

… if we leave the federal government in control of everyday health care decisions, it is more likely that our health care system will devolve into a single-payer system, which would require a massive federal spending increase.

Interesting because it may be that Senators Moran, Lee, Collins, and Rand and their no votes may help pave the way for that single-payer system to become reality. May, but we can’t really say for sure. That’s because either Obamacare remains in place largely untouched because GOP conservatives and moderates are far too apart on the complex trade-offs.

Or – as Senator Moran seems to be suggesting and which may be the only alternative to Obamacare that is feasible – we will have a significant devolution of power back to the states as far as health care policy goes. Something that will take years of litigation that will end up – on multiple occasions more than likely – in the Supreme Court. And which will mean that health care will be provided in very different ways in Texas, for example, compared to California. For example.

Actually, it’s not really the trade-offs that are that complex. It’s the endless policy iterations that are used to mask subsidies and taxes under complex legal language. Because the trade-offs boil down to that cliched but still-true trinity of what is achievable under America’s (and any) health care system. There are three basic truths:

  • You can lower/raise premiums
  • You can raise/lower deductibles (that is lower/raise the amount you pay out of pocket)
  • You can raise/lower taxes/subsidies

And you get to choose two out of those three. Doing all three is impossible. Yes you could keep taxes constant and increase the deficit with more government subsidized care and lower premiums. But even there you run up against fiscal constraints built into the budget process.

Right now, polling suggests that a clear majority of Americans do not want a market based health care insurance system. The voters themselves basically hate the BCRA. And Senators will now feel even less obliged to risk their re-election prospects by voting yes, now that Collins, Rand, Lee, & Moran have come out against it. Voters are also mad at the higher Obamacare premiums that are the inevitable result of adverse selection: healthy younger voters staying away, and older sicker voters buying in to the ACA. And of course insurance companies are going broke under Obamacare’s rules and mandates.

That’s not sustainable. You either repeal and replace the ACA, or at least dramatically reform it. But reforming Obamacare is running into resistance from hospital groups and insurers – the former because the hospital business is booming thanks to the ACA, the latter because of the subsidies the insurance industry receives under Obamacare. So even a reasonable but modest reform is impossible apparently. Or you increase government involvement: more taxes more regulations, more direct federal involvement in how your health care is provided.

That means only one thing. Repeal and replace will likely fail. Obamacare will continue it’s zombie existence and it will be saved by the only way that a health care zombie plan can be saved.

A government take over of healthcare in a process that will effectively become a single-payer system over the coming years. The only place left to fight it seems to be at the state level. Would a president Kamala Harris (don’t laugh … don’t laugh!) hesitate to send in troops in 2025 to quell an unruly state who tried to provide health care in a more free market way? Or more likely, cut off all federal funding to said state(s)?

Maybe this theoretical, will remain just that, a silly theoretical. But we are now one step closer to that possibility.

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