Even as it takes shape, Donaldcare beats Obamacare hands down

WASHINGTON, D.C. — Even after narrow passage in the U.S. House of Representatives of the American Health Care Act this month, we don’t know fully what “Trumpcare” will become. But we do know what Obamacare has produced — broken promises, disappointment, government overreach and dysfunctional health insurance markets around the country.

And we do know that after the Senate has its own say on the issue over the next few months and further difficult but necessary compromises are reached, the final version of Trumpcare will turn out to be whatever a majority of both bodies delivers to President Trump for his signature. Hint: He will say “It’s Great!” Great or not, it will in any case be better than Obamacare, even though that’s admittedly setting a pretty low bar. We should not forget that Obamacare—the Affordable Care Act, or “ACA”—failed to deliver on its inflated promises. Enrollment in its state-based marketplaces fell well short of initial projections and stalled. Insurance premiums there spiked significantly higher in recent years. Many participating private insurers incurred substantial losses and started looking for the exit doors. Most ACA coverage gains were limited to individuals heavily subsidized by taxpayers or pushed into expanded Medicaid coverage that paid less for health care and accordingly delivered poorer results. Obamacare tried to shift and hide health care costs, but it failed to reduce them. The Obama administration even tried to stretch the healthcare program beyond its legal limits, but it simply could not subsidize, coerce, and tax enough people and businesses to reach its goals.

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More fundamentally, Obamacare critics objected to the federal government's growing role in limiting their personal health care choice. So what’s ahead, instead? Early, cautious steps in a different direction that starts to rebalance our investments in health care and hopefully better health to emphasize, on the margins. For instance, it’s likely to prefer:

• Private markets over bureaucratic edicts,
• Positive incentives to obtain and maintain affordable coverage, instead of mandates and ever-growing regulations to buy what you don’t want,
• More decentralized decision making by patients, their trusted agents, and state and local officials
• Lower taxes; higher-value choices; and clearer rewards for performing better, working harder, and acting more responsibly, and
• Better targeted subsidies that still ensure generous protection of the most vulnerable Americans.

The legislative effort to begin this policy shift remains a work in progress, with plenty of areas needing far more refinement and improvement than where last week’s House bill finished. The final version of Trumpcare will look different, in order to ease transitions from the excesses of Obamacare without creating new ones in the opposite direction. For example, we should expect a more gradual reduction in the future growth of Medicaid, a rebalancing of insurance subsidies to be somewhat more income-sensitive, further boosts in safety-net funding and regulatory protections for high-cost individuals and a greater willingness to accommodate different regional and political perspectives. Our political processes and institutions ultimately curb or punish extreme or unwise swings that are too fast, too unpopular, or too destabilizing. However, we do know that the legislation that is enacted finally will effectively end the unpopular individual mandate to purchase only federally approved insurance, eliminate the employer coverage mandate, repeal a medley of growth-reducing taxes and allow average Americans a greater choice and voice in how they want to spend their resources to protect and enhance their health. Health policy reform should do even more, but the legacies of our partisan politics, sunk costs, institutional inertia, shortened time horizons and deeply-held illusions about the leveraging of other people’s money set low ceilings on what can be achieved in the near term. Hence, we may have to settle for the advice ascribed to the late, noted sage Yogi Berra, “When you come to a fork in the road, take it.” Tom Miller is a resident fellow at the American Enterprise Institute and co-author of “Why Obamacare Is Wrong for America.” He holds a law degree from Duke University. Readers may write him at AEI, 1789 Massachusetts Avenue NW, Washington, DC 20038