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The Way To Get A New Health Law Is To Create A Crisis, Policy Consultant Says


Let's follow up on one of this election season's biggest talking points.


DONALD TRUMP: We will be able to immediately repeal and replace Obamacare.


TRUMP: Have to do it.

INSKEEP: President-elect Donald Trump has promised to replace the Affordable Care Act and so have many other Republican lawmakers for years, including House Speaker Paul Ryan, who has his own plan. Yet in recent days, Trump has affirmed that he would like the popular parts of Obamacare to stay, like a guarantee that nobody loses insurance for a pre-existing condition, for example. And Republicans have struggled for years to agree on any replacement.

Robert Laszewski is a health policy consultant who had a long career in the insurance industry, and he helped us to try to figure out what might happen now. He's thinking of how Republicans could act - repeal Obamacare now, try a replacement later.

ROBERT LASZEWSKI: They'll take the money away in early 2017, and they'll create a crisis. They'll say that the money for the current law will stay in effect for 2017 and probably 2018. But the crisis is that the Congress has to agree on a comprehensive replacement, both for Medicaid and for the health insurance exchanges, by January 1, 2019, or we'll have somewhere between 16 and 20 million people fall off the coverage.

INSKEEP: Wouldn't it be a little more calm to work out what they're going to do and then do it, rather than create a crisis first?

LASZEWSKI: Well, we've all lived through the U.S. Congress over the last 20 years. And we know that bipartisan agreement is almost impossible, if not impossible. Likely, the only way that we can get a new health law is to create a crisis.

INSKEEP: Is it likely that any new law is going to contain large provisions of the current law?

LASZEWSKI: Any new law will absolutely contain large provisions of the current law because it's health insurance. I mean, you've got to do things like figure out how to deal with pre-existing conditions and what you do with children who are now on their parents' health plans until age 26. You've got millions and millions of people that are now eligible for Medicaid. These are the elements of health insurance reform that have to be dealt with no matter who writes the bill.

INSKEEP: I want to remind people that the Medicaid expansion is very important here.


INSKEEP: Medicaid was expanded, health program for the poor so that it covers people who make a little more money but are still quite low income.

LASZEWSKI: That's right.

INSKEEP: What happens to that part of Obamacare in some form of replacement?

LASZEWSKI: Well, Donald Trump hasn't put a detailed plan on the table for what he's going to do with Medicaid. I think it's best to look at Paul Ryan's plan. He would roll back the Medicaid expansion to the way it used to be three years ago, which means lots of people lose their Medicaid coverage. Then Ryan would provide financial assistance for the very low income people to buy a mainstream health policy. Republicans are arguing that Medicaid's a lousy place to be and you're better off being in the standard insurance plans.

Now the devil's in the details on that because just how much financial assistance is he going to provide for people? But what Republicans have said is that if they roll back something like the Medicaid coverage, they will replace it with something that they would argue is better. But the devil's in the details.

INSKEEP: And let's talk about that because the basic principle is still the same. Right? You have people who need health insurance, and the government is going to pay money to help them get it. The only difference is it might be through a private company instead of Medicaid. Why is that such a big deal?

LASZEWSKI: Well, Democrats generally believe, as represented by Obamacare, that the best way to expand coverage is through a government-run program. They believe that government will regulate the system to keep costs under control. Republicans believe that expanding government programs just adds to entitlements. And Republicans believe you need to bring the market to bear for more efficiency. So there's not a difference of opinion that people should be covered, but there's a fundamental difference in how they should be covered.

INSKEEP: Although the way that it's going to go down in some cases is you'd have less coverage. Right?

LASZEWSKI: By regulating the health insurance plans less, people would find plans with less coverage, but they'd be more flexible and more suited to their needs. Right now, the plans are very regulated and very structured so that, for example, the standard silver plan for a family of four probably costs around $1,000 a month with a $7,000 deductible.

But the other thing to remember here about the cost of health insurance plans - it's not just about benefits. The fact is that only about 40 percent of the people eligible for Obamacare subsidies have bought them, and they are disproportionately sick. And as a result, the costs of these plans are very expensive. A number of actuaries in the health insurance business that I've talked to believe that if they could offer more attractive plans, we could get the enrollment up. And if you go from 40 percent of the eligible signing up to 75 percent of the eligible signing up, we should be able to reduce the cost of these health insurance plans 30 to 40 percent just because we've got far more healthy people in the market.

INSKEEP: Do you think that if this issue had been less politically toxic that some of these adjustments that you're describing could have been made over the last several years - make some changes this year, make some changes next year and keep tweaking the law until it makes sense for everybody?

LASZEWSKI: What is really unfortunate about the Affordable Care Act, or Obamacare, is Democrats rammed it through in 2010 over the objections of the Republicans. And this has been a hot-potato political issue since that point. Now, I just hope that Republicans don't end up doing the same thing this time - that they don't steamroller their brand of health insurance reform through. So I really hope the Republicans and the Democrats have learned from this lesson and we can see some bipartisanship here.

INSKEEP: Have you heard any Republicans say what you're saying, we want to do something that's bipartisan, so it's more durable?

LASZEWSKI: They all say that the week after the election, and we'll see. And, you know, I've talked to some Democrats that are basically saying, we're not going to cooperate. They want to dismantle Obamacare, they'll do it over political dead bodies. So it's - you know, it's going to take two to tango here.

INSKEEP: And let's remember, that's one of the reasons the Republicans were so absolutely opposed at the beginning - they didn't want Obama to succeed. They were pretty overt about that.

LASZEWSKI: That's right. Republicans didn't want Obama to succeed, and this is part of the reason we're in the mess we're in. You know, I would suggest to you we may have the same problem right now. How many Democrats don't want Trump to succeed? So it really depends upon whether these people can work together or not. If we can't have bipartisanship on the next iteration of health insurance reform, we're just going to have the mirror-image political bickering that we had the last four years trying to implement Obamacare.

INSKEEP: We've heard stories of people immediately after the election rushing out and getting insurance on the exchanges, wanting to get benefits before they disappear.

LASZEWSKI: That's right.

INSKEEP: Should people who need health insurance be worried that benefits could rapidly disappear?

LASZEWSKI: People who need health insurance should not worry about Obamacare continuing for at least 2017 and almost certainly for 2018.

INSKEEP: Bob Laszewski, thanks very much.

LASZEWSKI: You're welcome.

INSKEEP: Laszewski is a health policy consultant who had a long career in the insurance industry. Transcript provided by NPR, Copyright NPR.