Commentary: Embracing a replacement for Obamacare will require compromise on all sides

The latest iteration of the House of Representative’s health care bill to repeal and replace the Affordable Care Act, now called the American Health Care Act (AHCA), emerged earlier this month and already individuals from both sides of the aisle, as well as many health industry groups are expressing their displeasure for a variety of reasons. If the bill survives, it will almost certainly look very different than it does now. So what are we to do?

In one respect, the contortions and transformations that this bill will likely go through are all a part of how a bill becomes a law. Different interests weigh in, and coalitions are constructed around a bill so as to create a critical mass of stakeholders to move it forward. Call it Politics 101. What is different with the AHCA, as compared to other bills, is that Republican leaders have telescoped this process into a much shorter time frame – the plan is to have an approved bill by April 7, and, conversely, there is much less appetite for compromise.

But it is worth asking what elements of this bill would we be willing to make a deal on, and which are less negotiable.

Looking at the AHCA from the perspective of a ACA proponent, I am willing to examine alternatives to the mandate, which requires that all individuals purchase health insurance. This is a central sticking point for many opponents of the bill. I hold on to the premise that for the individual insurance market to be functional and affordable, an insurance risk pool must contain a large number of healthy individuals to offset the costs of the fewer sick individuals.

One way to get that is to require that all have coverage, in the manner of the ACA. But is such a mandate the only way to obtain this? Prominent analysts such as Avik Roy, Paul Starr, and Uwe Reinhardt have all floated possible alternatives that are largely centered either on more market-based incentives or opt-out approaches, including universal coverage. These alternatives tend to be unorthodox and creative, and require suspending ideology, but perhaps that is more of what is needed in the current policy context.

The piece of the AHCA that I would be much more reluctant to accept involves how it proposes to repackage the federal financing for Medicaid. Medicaid has been providing insurance coverage to poor people for the past 50 years. There is much concern over Medicaid’s overall costs and individual access to care, but given that the program covers upwards of 70 million people, changes should not be taken lightly.

There are many other parts of this bill, each of which can be considered in terms of how important they are to everyone involved with the passing of the bill. Starting with those parts that are generally more negotiable, the parameters of a health care bill founded more on consensus could emerge. Then it would be time to tackle the tougher stuff.

But all this would take more time and require more compromise than seems to be out there now. As a result, what is likely to happen appears a more Republican process, in that the fate of the bill will be left to the vicissitudes of the unregulated market where interests will take precedence. It will not be pretty, but at least it should not take long. 

Dr. Stephen Metraux is director of the health policy program at University of the Sciences and associate professor of health policy and public health. Dr. Metraux has done extensive research on homelessness and housing, mental illness and community integration, prison reentry, and other aspects of urban health.


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