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The concept of universal coverage

The concept of universal coverage

January 7th, 2017 by Doyle McManus in Opinion Columns

President Barack Obama has embarked on his final campaign, this one aimed at making sure we miss him once he's gone.

He's giving a speech in Chicago next week to talk about his legacy. "I couldn't be prouder of the work that we've done," he said in a recent preview. "I can say without equivocation that the country is a lot better off: the economy is stronger, the federal government works better, and our standing in the world is higher."

It's not unusual for presidents to give a farewell address; the practice began, after all, with George Washington. Obama has a more practical reason: He's handing the keys to a successor and a party that have promised to dismantle everything he's done, brick by brick.

Donald Trump's Republicans have vowed to repeal Obama's health care law, abolish his financial reform law, and undo his executive orders on immigration and clean energy. As Edward Luce of the Financial Times wrote: "It will be as if Mr. Obama was never here."

But their No. 1 target, Obamacare, may be safer than it seems.

The reason is simple but underappreciated: Because of Obamacare, Republicans have inherited an obligation to ensure access to affordable health insurance for every American—a duty the federal government didn't have before. They could disavow the burden—but they haven't. Indeed, Trump has embraced it.

During his campaign, the president-elect promised to enact "a beautiful new plan (for) much better health care at a much lower cost."

After the election, he repeated the pledge, saying: "Everybody's got to be covered."

In the short run, that means Obamacare has to continue operating until a new plan is ready. Indeed, Democrats have already been taunting Republicans with what some call the Pottery Barn rule: "You break it, you own it."

"We're talking about a three-year transition," Sen. John Cornyn, R-Texas, said. "People are being understandably cautious to make sure nobody's dropped through the cracks."

Next week, the Senate is expected to vote on what its leaders have called the "Obamacare repeal resolution," but it won't actually repeal the law; it will merely be a promise to repeal it later.

After that, Republicans in the Senate and House will get to work on a new plan, drawing on conservative proposals drafted well before the election. The irony is that the drafts most likely to succeed share some basic features with Obamacare.

They agree on the basic goal of universal coverage—or, at least, universal access to affordable insurance. They agree on subsidies to make it possible for low- and middle-income families to afford insurance—in most cases, in the form of tax credits ("refundable" credits, so they would go even to people who don't pay taxes). Some Republican plans would even keep the state insurance exchanges that Obamacare set up—and in at least one case, the federal healthcare.gov exchange as well.

Naturally, there are big differences too, all of which make the GOP proposals less generous and less universal in coverage than Obamacare.

Most of the Republican alternatives would push many people into bare-bones catastrophic insurance policies, with less coverage than Obamacare offers. (They would pay less, but get less.) They would cover fewer people too—at least 4 million fewer, according to one forecast. And there's a controversial divergence on guaranteed coverage for people with preexisting conditions: The GOP plans provide it only for users who have maintained "continuous coverage" for some period of time.

James Capretta, a conservative health policy expert at the American Enterprise Institute, believes the political imperative will be for the GOP to deliver something credible on its promises.

"They're halfway to where they need to go," he told me. "They need to make sure everybody in the country can get health insurance if they want it. And that the prices are right—that this looks to most Americans like a reasonable way to get health insurance."

"Voters and history will judge them to have failed if the end result is millions of people becoming uninsured again," he said.

If Republicans can't do it on their own, they might even have to try an unusual Plan B: bipartisan compromise.

Either way, the basic premise that the federal government has an obligation to make affordable, comprehensive health insurance available to everyone, with near-universal coverage, appears as if it's going to stick.

The result won't be the plan Obama wanted—but in the long run, he'll still deserve credit from history.

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