What's next for health care?

There's a secret that Republicans in Congress would rather not speak out loud: Now that their effort to repeal the Affordable Care Act has gone down in flames, a lot of them are relieved.

This process brought home to them that they simply couldn't deliver what the public wants on health care, particularly not if they wanted to be true to their anti-government ideology. They're more than happy to have the issue just go away, so they can move on to the things they really want to do, like cutting taxes.

But while the current threat to Americans' health care may have passed, the system still has deep problems. We still pay much, much more for our health care than any other country on Earth — yet we leave millions without coverage. Insurance premiums are too high. Nobody likes deductibles.

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American health care is still broken. How do we fix it?

There are some actions our political leaders could take that would stabilize the system and bring coverage to more people, if they're willing — but that's a big "if." First and most important, the Trump administration needs to stop sabotaging the individual market. President Trump keeps threatening to "let ObamaCare die," but what you may not realize is that he's already working to make that happen, at least the part of it where people who aren't covered by their employers and aren't on a government program get their insurance.

One of the biggest ways the administration has brought uncertainty to those markets is by threatening to withhold cost-sharing payments that cover out-of-pocket costs for low-income people, which has led insurers to consider fleeing from the market. The administration has cut back on the advertising that used to be in place to encourage enrollment, and put out a series of anti-ObamaCare videos to actively discourage people from signing up for insurance. They cut the open enrollment period in half (from 90 to 45 days), in the obvious hope that people will not sign up in time. They cancelled contracts for organizations helping guide people through the enrollment process. And they're threatening to not enforce the individual insurance mandate, which would cause younger and healthier people to not bother getting insurance until they become sick.

What all that amounts to is that the administration is intentionally trying to create a "death spiral" in the individual market, where premiums skyrocket and only sick people remain in the pool. And there's more: Can we trust Secretary of Health and Human Services Tom Price, whose hatred of the Affordable Care Act burns with the fire of a thousand suns, to make sure that Healthcare.gov is free of technical problems, that the federal exchange is operating efficiently, and that call centers to answer consumers' questions are fully staffed and trained?

This is all stunning in its cynicism and cruelty, but by now that shouldn't be too much of a surprise. Now, however, the Trump administration has to realize that they'll be held responsible for whatever happens — it won't be enough to just blame Democrats for the results of their own actions.

No matter what the administration does, the holdout states need to go ahead and accept the ACA's expansion of Medicaid. Nineteen Republican-run states refused the expansion, even though the federal government was offering to pay almost all the cost, for an initiative that would have given their citizens insurance, helped rural hospitals, and even aided state budgets. The Kaiser Family Foundation estimates that at least 2.6 million Americans fall into this gap created by one of the most cruelly partisan decisions imaginable. Those GOP governors and legislators made their point, immiserating their own people in order to give Barack Obama the finger. But Obama is gone. How long will they let their decisions be dictated by spite?

We should also create a Medicaid buy-in for people who live in areas without other insurance choices. Republicans have lamented that there are places where there are few insurers for people to choose from — in some counties, the last insurer has left. In fact this is almost entirely a problem of Republican states, where the state government hasn't tried to establish a well-functioning insurance exchange. But the people in those places need help now. So why not let them buy in to Medicaid? It would be much easier than trying to come up with some complex series of incentives that might or might not lure private insurers back to places they've left.

There are many other specific steps that can be taken to stabilize the individual market (here's a good list). And yes, nearly all of them involve government working to shore up private insurance. But even Republicans should realize now that their free market plans for health care — a great big "You're on your own" to the American public — failed not only because they were terrible ideas, but also because the public didn't want what Republicans were selling. They promised over and over again to repeal the ACA, but they also promised lower premiums, lower deductibles, boundless provider networks, and limitless "access" to care. They couldn't deliver all that because it was impossible.

In the coming years, Democrats are going to be advocating a dramatic expansion of government's role in health care. "Single payer," which means different things to different people, is on its way to becoming the consensus position in the Democratic Party. Republicans find the idea horrifying, but this experience should teach them that they have no choice but to accept a strong government role, much as they might dislike it. They're in charge now, and they'll be held responsible for what happens to the system. They just need the courage to do the right thing.