Now that John McCain’s vote against Obamacare repeal and his call for full Senate hearings has pushed the healthcare debate toward bipartisan reform, what does it take to get the two sides together?

Interestingly, a bipartisan group of governors has already issued their recommendations. And McCain cited the concerns of fellow Republican Doug Ducey, Arizona’s governor, in rejecting the Senate repeal bill – many governors said that cutting subsidies not only to the Medicaid program but also the middle-income workers through the exchanges would force a return to the days of small and rural hospitals picking up the cost of uninsured care. In 2017, the federal government through the ACA is expected to give tax credits totaling $38 billion to about 9 million people.

“Congress should be working to make health care more affordable while stabilizing the health insurance market, but this bill and similar proposals won’t accomplish these goals,” said one statement issued by 13 governors – seven Democrats and six Republicans.* “The bill still threatens coverage for millions of hardworking, middle-class Americans.”


The governors then go on to get into the policy weeds on reinsurance, waivers and drug formularies, among others. Their overriding concerns, however, are to retain control over the health insurance markets within each of their states while shoring up and expanding the private insurance market through federal dollars.

That doesn’t sound like the “socialized medicine” that Senate Majority Leader Mitch McConnell keeps using as shorthand for a government takeover of the health care system. As The Economist and others have pointed out, even a single-payer system in many countries such as Canada retains private, for-profit medical providers. There are many paths in Europe, for example, to achieving universal coverage without the government taking over hospitals and employing doctors directly.

What are some of them? Reports in the Wall Street Journal, New York Times and The Economist point out that France and Canada have private doctors but a single-payer concept with basic government-funded insurance – people can increase their insurance through private plans, much like Medicare in the U.S. Switzerland and the Netherlands have private doctors and private insurance that everyone is required to buy, with government subsidies keeping premiums affordable and regulations keeping costs down. This last model is like Obamacare, but the subsidies are larger and the mandate is strictly enforced, resulting in 99 percent coverage vs. about 90 percent in the U.S.


What keeps costs down in Europe, Britain and Canada is a national, not a state or provincial, system that has a single payer. America has six or seven different payment systems when the VA, Medicaid, Medicare, Obamacare and employer policies are counted, and administration alone eats up 8 percent of health care spending (vs. 2.5 percent in Britain). Some U.S. hospitals report having more employees in their billing departments than beds. Total costs of U.S. health care eat up 17 percent of GDP vs. an average of 12 percent in Europe, even though Europeans score higher on almost every health and wellness index.

So how can America achieve universal coverage regardless of pre-existing conditions -- which is what most polls show most Americans want – but at an affordable price? The group of bipartisan governors is not quite ready for a single, national insurance system. But they are willing to consider benchmark standards similar to Obamacare, then have the federal government step in with bigger subsidies for the sickest patients with the highest claims. Under the ACA, those patients cannot be charged higher premiums because of their pre-existing health conditions. Insurers say they cannot sustain those losses without charging higher premiums to those patients or getting financial help.

The ACA offered that help by creating a federal fund to compensate insurers for their losses, but the fund wasn’t authorized by the Republican-controlled Congress after 2016. The 13 governors say restoring that fund would stem the tide of insurers leaving the marketplaces and encourage others to return. The next step, however, is to get more healthy people to sign up for insurance to expand the risk pool and raise more private funds, too.


The governors also want the ability to customize Medicaid if subsidies are going to be cut, including a work requirement in Arizona and replacing some high-priced drugs with generics. But all but one emphasized the importance of assuring basic health care for the poor and disabled – a sort of universal coverage similar to those over 65 on Medicare, but with states and the feds partnering on the payments and holding down costs.

How to get to that goal for all of the working middle-class, too, doesn’t have to be one-size-fits-all, as McConnell seems to imply when sneering about “socialized medicine.” The two basic paths are either direct government services, or subsidies and regulation of the private market. Most other industrialized countries have tried a combination, and their coverage is higher, their costs are lower and their health is greater. All of that information, along with the governors’ proposals, would come out were Congress to hold actual hearings and take testimony from all sides.

Maybe McCain ought to switch chairmanships from Armed Services to Health and Human Services – except where would he be when we need him on Russia, Syria and Korea?

*The 13 states are California, Delaware, Kentucky, Minnesota, Montana, Pennsylvania, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, and Wyoming.


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