By: Jane M. Orient, M.D.

The attempt by House Speaker Paul Ryan and other powerful Republicans to “repeal and replace” the Affordable Care Act (ACA or “ObamaCare”) has run into a buzz saw of opposition from both sides. Most proponents of the American Health Care Act (AHCA) concede that the Act is “not perfect.” But there is “political reality” to consider—what can make it through the congressional sausage-making machine? Already Congress is telling us the most important consideration for them: staying in power. The 2018 election will be a “bloodbath” for Republicans if AHCA is not passed—or else if it is passed.

The outcome of the midterms supposedly depends on how unhappy the American people are. But the political reality is that the happiness of the donor class is far more important. Most of the donor class resides in the Swamp. Perhaps the best thing to say about AHCA is that it has the right enemies: the AMA, big hospitals, and some big insurers (who all favor ACA).

Leaving aside political reality and looking at actual reality, these are some facts:

• It is very difficult to take away an entitlement, and ObamaCare entitlements have had 7 years to take root and spread. And while the media will be focusing on sad stories, the real losers with clout are not sick and dying individuals but the hospital/Pharma/managed-care cartels.
• Coverage is not the same thing as care. Denizens of the Healthcare Swamp adroitly confuse the two. Coverage often blocks care, as with narrow networks, and inevitably drives up the cost.
• Government cannot provide care. Increasingly, it cannot even finance care, as governments at all levels are mired in deficit spending. Its programs forcibly redistribute a decreasing pool of assets.
• Guaranteed issue (no “discrimination” against people with pre-existing conditions) is not insurance. It destroys insurance; low-risk individuals will not buy it unless forced to do so.

Ohio Governor John Kasich said, “We cannot turn our backs on the most vulnerable. We can give them the coverage,… and make sure that we live in a country where people are going to say, ‘At least somebody is looking out for me.’”

In fact, Gov. Kasich, your congressman, the CEO of UnitedHeath Group, CareSource in Ohio (probably the chief beneficiary of Ohio’s Medicaid expansion), or the AMA are not looking out for you—but don’t mind using you to promote their own interests. The Medicaid expansion brought in far more new enrollees than the 5.5 million predicted, including 11.5 million able-bodied adults. Since resources for providing care were not expanded, funds are being diverted from the disabled and needy.

AHCA does not get rid of the basic flawed premises of ACA. Arguably, it cements them further. But is it a step in the right direction? The answer to that question ultimately depends on whether it permits a free market to develop outside the comprehensive managed third-party pre-payment NON-insurance model. If it has competition, that model will fail, and vast resources now diverted to the rapacious Healthcare Swamp will be freed up for actual care.

The question is not whether people will “lose coverage.” According to the Congressional Budget Office (CBO) analysis, most of the increase in the number of uninsured “would stem from repealing the penalties associated with the individual mandate. Some of those people would choose not to have insurance because they chose to be covered by insurance under current law only to avoid paying the penalties, and some people would forgo insurance in response to higher premiums.”

In other words, millions of Americans see ACA insurance as such a bad deal you have to force them to buy it. They would choose to reject it.

There are a few good features and many bad ones in AHCA. Tax “credits” are subsidies if people don’t owe taxes. But if credits refund payroll taxes, ending discrimination against people who buy their own coverage, that’s a step toward fairness and freedom. So is the liberalization of health savings accounts—especially if people have savings because they are freed from requirements to buy expensive comprehensive coverage, and to pay for people who decline to purchase insurance as long as they are healthy. The AHCA penalties for failure to maintain continuous coverage—like those in Medicare Part B—would help to discourage system gaming. However, any credits must go to patients, not third parties. And the government needs to stop dictating the terms of voluntary insurance contracts, including premiums.

Freedom is possible only if people are responsible. The worst feature of AHCA is perpetuating the myth that “non-discriminatory” coverage for pre-existings is insurance rather than a pipe dream.

We can hope that AHCA, if properly amended, might be a wedge of freedom rather than a way station on the road to a full crony capitalist/government takeover. The ultimate goal must still be the restoration of a free market. We need to get rid of the subsidies, mandates, and regulations that stand in the way, feeding the Swamp and propping up ObamaCare. ACA needs to die. The unshackled free market needs to kill it, before or after Congress repeals every last word.

Jane M. Orient, M.D. obtained her undergraduate degrees in chemistry and mathematics from the University of Arizona in Tucson, and her M.D. from Columbia University College of Physicians and Surgeons in 1974. She completed an internal medicine residency at Parkland Memorial Hospital and University of Arizona Affiliated Hospitals and then became an Instructor at the University of Arizona College of Medicine and a staff physician at the Tucson Veterans Administration Hospital. She has been in solo private practice since 1981 and has served as Executive Director of the Association of American Physicians and Surgeons (AAPS) since 1989.  Dr. Orient is the 2017 recipient of The Edward Annis award for medical leadership.