I’ve never been the biggest fan of the Patient Protection and Affordable Care Act (aka “Obamacare”). It’s not perfect. It’s too complicated. The cost containment mechanisms built into the health care exchanges haven’t lived up to expectations. The Supreme Court ruled that states had a right to turn down the Medicaid expansion that provides affordable health insurance to the working poor and a staggering 19 states (including the second and fourth biggest by population) did so. Read More

I’ve never been the biggest fan of the Patient Protection and Affordable Care Act (aka “Obamacare”). It’s not perfect. It’s too complicated. The cost containment mechanisms built into the health care exchanges haven’t lived up to expectations. The Supreme Court ruled that states had a right to turn down the Medicaid expansion that provides affordable health insurance to the working poor and a staggering 19 states (including the second and fourth biggest by population) did so.

Overall, the U.S. health care system is still the most expensive in the world and still leaves almost 10 percent of the population uninsured, a higher portion than other major industrialized nations.

President Obama himself favored the much simpler approach, single-payer, earlier in his career. But, as president and faced with the question of what kind of program he could push through Congress (that rules out single-payer because of the power of the private health insurance lobby) without any Republican votes (not because he didn’t want Republican support but because Republicans decided to just say no) the Affordable Care Act was what he was able to sign into law, and that just barely.

Because he needed 60 votes in the Senate and there were exactly 60 Democrats, he ended up having to negotiate with the most conservative Dem senators and settle for whatever he could get them to buy, and then throw in a couple of specific sweeteners for the last holdouts that gave the whole process an odd smell. Republicans were mostly opposed from the get-go and pounded the few wobbliest Republican senators into submission. In the end, they all voted nay.

The program has done a lot of good. The single best measure of that good is that the portion of Americans who are uninsured has fallen by slightly more than half, from about 20 percent to a little under 10 percent, which is an all-time low for our country (but, as I said above, still high by wealthy-nation standards. Many of our overall health outcomes are also still poor by comparison. Athough that fact probably has a number of interlocking explanations, lack of insurance coverage for almost 30 million Americans is a big factor.)

The cynical (or perhaps just misguided) decision of those 19 red states to turn down the Medicaid expansion is a big factor. If I try really hard, I can see that decision as an act of principle. But, if that’s what it is, it is an act that puts the principle of restraining the growth of government ahead of the powerful human need of working-poor families in those states to have access to basic health care. And if it is that, it was an act of principle that required no sacrifice, no compassion and no political courage by those who made it.

The Republican campaign of vilification of the law has been powerful and effective. They focus on problems with the program, exaggerate those, and never bring up the important gains, such as the halving of the uninsured rate. In a culture more steeped in intellectual honesty, this would render such criticism laughable. But in the polarized and partisanized U.S. political environment, they got away with it. As a certain president-elect might tweet: “Sad.”

At a certain point, once they had the votes in Congress to do it, the Republicans started routinely voting to repeal the law, knowing Obama would veto the repeals. They did this more than 60 times, which, to me, is a sad comment on how they chose to use their time and their majority. In criticizing Obamacare, Republicans like to point out that none of them voted for it, as if the law was crammed down their throats, but that overlooks the lengths to which Obama and congressional leaders went to make it a bipartisan process.

But now it’s different. The next time the Republicans repeal the ACA, it will be repealed, and that will be quite soon.

At some point, the Republicans adopted the slogan “repeal and replace.” The general idea was that their replacement would cost less and do more good for the health of Americans. But, as you probably know, they never produced an actual bill to create an actual program that could be actually scored by neutral experts to determine whether the not-really-existent replacement program would indeed do more good at less cost.

It’s kind of amazing – one might even call it shameful – that, if they have a such a plan, they have never put it on the table. Or perhaps there is no such plan. Because Republicans have been so careful never to take note of the reduction in the uninsured numbers under Obamacare, I am quite concerned that they don’t consider this to be an important measure of the benefits of national health care system.

Donald Trump has also been an Obamacare basher and has been somewhat incoherent on health policy in general. If we go back a way, he seemed to favor Canadian style single-payer. If that surprises you, here is a quote from his year 2000 book “The America We deserve:”

We must have universal healthcare. … I’m a conservative on most issues but a liberal on this one. We should not hear so many stories of families ruined by healthcare expenses. …

Doctors might be paid less than they are now, as is the case in Canada, but they would be able to treat more patients because of the reduction in their paperwork..

The Canadian plan also helps Canadians live longer and healthier than Americans. There are fewer medical lawsuits, less loss of labor to sickness, and lower costs to companies paying for the medical care of their employees. If the program were in place in Massachusetts in 1999 it would have reduced administrative costs by $2.5 million. We need, as a nation, to reexamine the single-payer plan, as many individual states are doing.

That may have been his ghostwriter’s opinion, but can we assume that Trump at least read it before it was published under his name?

And if that’s ancient history, here are words that actually came out of his mouth during the 2016 campaign, such as, in a September (2016!) interview with Scott Pelley on “60 Minutes”:

TRUMP: “Everybody’s got to be covered. This is an un-Republican thing for me to say because a lot of times they say, ‘No, no, the lower 25 percent that can’t afford private. But —’ ”

PELLEY: “Universal health care.”

TRUMP: “I am going to take care of everybody. I don’t care if it costs me votes or not. Everybody’s going to be taken care of much better than they’re taken care of now.”

PELLEY: “The uninsured person is going to be taken care of. How? How?”

TRUMP: “They’re going to be taken care of. I would make a deal with existing hospitals to take care of people. And, you know what, if this is probably —”

PELLEY: “Make a deal? Who pays for it?”

TRUMP: “— the government’s gonna pay for it. But we’re going to save so much money on the other side. But for the most it’s going to be a private plan and people are going to be able to go out and negotiate great plans with lots of different competition with lots of competitors with great companies and they can have their doctors, they can have plans, they can have everything.”

It’s fairly amazing that this didn’t cause a bigger stir at the time – September of 2016, after he was the nominee. Somehow or other, it qualifies under the (to me) absurd notion that Trump’s supporters took him “seriously, but not literally.” If we took him literally, he will be a proven liar and promise-breaker if it turns out that he does not produce a health care system that takes care of “everybody” and the government “pays for it.” That’s what he promised.

It sounds far-fetched. But yesterday, Trump said to the Washington Post just this past weekend something fairly similar to what he said to “60 Minutes.” It led to this lede on a piece that ran in today’s edition of the Post:

President-elect Donald Trump said in a weekend interview that he is nearing completion of a plan to replace President Obama’s signature health-care law with the goal of ‘insurance for everybody,’ while also vowing to force drug companies to negotiate directly with the government on prices in Medicare and Medicaid. Trump declined to reveal specifics in the telephone interview.

I have no idea how seriously to take this, and if it is more true than false it will be extremely interesting to see how much Republican support he can attract for it. If it turns out to be serious, it will be a big moment in the emerging understanding of the Trump presidency.

But suppose he doesn’t keep that promise literally of “insurance for everybody” but only signs up for a replacement for “Obamacare” that meets Obama’s own criteria for what he would call a successful version of Trumpcare.

In his farewell speech last week, Pres. Obama said:

If anyone can put together a plan that is demonstrably better than the improvements we’ve made to our health care system and that covers as many people at less cost, I will publicly support it.

The audience applauded. Personally, I’m prepared to take Obama at his word. And I feel the same way. Show me a plan that will provide health care to more people at less cost with at least roughly equal coverage and I will both eat my hat and greatly rethink my fears about what the next four or more years are going to be like for at least lower working-class Americans.