Affordable Care Act

Why Trump Can't Fix Health Care

People want it all, but they can't have it.


ACA protest
Ronen Tivony/ZUMA Press/Newscom

Bill Clinton tried to fix America's health care problems and was shot down by Congress. Barack Obama got his solution enacted only to find most people didn't like it. Republicans who voted repeatedly to repeal Obamacare and replace it with something far better have found it fiendishly hard to agree on how.

It could be that our health care problems don't get solved because of partisanship, incompetence, corruption or dishonesty among our elected officials. Or it could be because those problems are not soluble.

Oh, some of them can be solved, for sure. But not all at once, and not within the constraints of our political environment. We have trouble accepting that. So we muddle along with a system that is riddled with flaws and causes a lot of dissatisfaction.

The changing perceptions of the Affordable Care Act are a marvel to behold. It was so controversial that it barely got through Congress in 2010. Long before it was fully implemented, it was unpopular, and it mostly remained so.

Republicans ran against it with great success in the congressional elections in 2010 and 2014, and Donald Trump won last year after calling it a "disaster" that he would repeal and replace with something "much better and much less expensive." As one of Ernest Hemingway's characters said, "Isn't it pretty to think so?"

But something shocking happened on the path to the repeal of Obamacare: It began to look better. In the latest poll by the Kaiser Family Foundation, 49 percent of Americans said they liked it, the highest figure since 2010, and just 44 percent didn't, down from 53 percent in 2014.

What accounts for the shift in sentiment? One factor is that when it comes to their health care, Americans nurse a deep distrust of change. They may not be satisfied with what they have, but they assume anything different will be worse.

Another is that a lot of them really didn't know what the ACA did but disliked it because they associated it with a president they opposed. Given that Obama's approval rating hovered around 50 percent for most of his second term, it's not surprising that his signature initiative evoked widespread disdain, particularly among Republicans.

Stubborn ignorance also plays a role. An NPR/Ipsos poll in January found that more than half of Americans didn't realize that the number of people with health insurance rose under Obamacare. One in three mistakenly thought it put restrictions on end-of-life care—remember the "death panels"?

The ACA also clashed with intractable preferences. It forced individuals to purchase insurance. It meant more government interference in private markets. It expanded a major entitlement, Medicaid. It required new taxes. It didn't reduce total health care expenses for most people. All of these features grated.

And Americans are not slaves to logic or consistency. Opposition to this massive federal program has been particularly high among seniors—most of whom are covered by that massive federal program known as Medicare. The implicit attitude: Big government for me, but not for thee.

Only lately has it occurred to many detractors that ACA also has elements that they would rather not surrender—such as allowing young adults to stay on their parents' policies until age 26, barring exclusions for pre-existing conditions, mandating free preventive care, giving subsidies to moderate- and low-income people and expanding eligibility for Medicaid.

Trump has led voters to believe they can have all the stuff they want and none of the stuff they resent. But neither he nor anyone else has found a plausible way to accomplish that.

The mournful realities are inescapable. If you remove the individual mandate, you allow younger and healthier people to opt out, which would mean higher premiums for older and sicker ones. If you cut the cost of Medicaid, you leave a lot of poorer Americans without coverage, forced to rely on expensive emergency room care. If you eliminate the taxes, you raise the federal deficit.

You can't have it all. Our aversion to this simple truism has yielded a dubious achievement: Compared with other Western nations, we have more people without insurance, spend far more of our national income on health care and are less happy with our system. That's what you get when you resist fundamental tradeoffs.

Americans who want a solution that has no downside don't really want a solution. Not to worry: They won't get one.

© Copyright 2017 by Creators Syndicate Inc.