Eugenics, such an old-fashioned idea

It's the age of genetics.  Billions of dollars have been spent on identifying genes for important traits like diseases, fun traits like ear wax type and hair color, politically-charged traits like who we vote for and whether we're criminals, and much more.  "Precision Medicine," the idea that with bigger and better genetic data we'll be able to predict future diseases and then, presumably, prevent them, is au courant, and well-funded.

The assumption that genes determine not only our disease futures but our personalities, our preferences, and our behavior, appeals to a lot of people; some of us are naturally good and some of us are naturally bad.  And this has lead many of us to worry about the return of eugenics, the darwinian idea that populations can be improved by controlled reproduction.  That is, that we control their reproduction.  Those of us who are naturally bad just shouldn't be allowed to reproduce.  This was an idea that early 20th century America translated into the forced sterilization of the intellectually or socially inferior other, and that the Nazis translated (in many ways copying our lead) into mass murder of anyone they didn't like.

It turns out, though, that the worry about eugenics is now out-of-date.  It's too finely-honed a tool. The Republican majority in the US House of Representatives, with the enthusiastic support of our 45th president, has just passed a bill to repeal and replace the Affordable Care Act (ACA), President Obama's signature program to expand affordable access to medical care to 45 million people who had no health insurance, and to those for whom it was prohibitively expensive.

One of the most humane, important, and best-liked provisions of the ACA was that it did not allow insurers to discriminate against people who had "pre-existing conditions", illnesses that preceded their insurance coverage.  Insurance companies don't like to have to cover sick people because they cost money.  Fair enough, I suppose, given that insurers are businesses, not philanthropies, and have to make a profit (unlike a civilized country's national healthcare system, which is by and for the people rather than the plutocrats).  But, this is how all insurance works, car, home, flood and otherwise -- we all pay in, some of us cost more than we pay in, and some of us cost less.  If it's only sick people, or bad drivers, or people in hurricane zones who buy insurance, insurance companies would all quickly be out of business, which of course is why we all are required to buy car and home insurance.

But it turns out that there are good moral reasons to discriminate against people with pre-existing conditions -- according to a member of the Republican, white, male "Freedom Caucus", the extreme, and let's be honest, extremely ill-informed right-wingers in the House, pre-existing conditions don't happen to people who live good lives.  (Funny how their new list of pre-existing conditions includes pregnancy, rape, sexual harassment, breast cancer, among many other things, but not erectile dysfunction or prostate cancer. Nice discussion of this topic here.)

To ensure that covering actual sick people was going to be affordable, the ACA mandated that everyone have health insurance.  The political right never liked this provision of the law -- depending on your reading, this was due to the libertarian view that governments shouldn't be able to require that we do anything, or because they didn't want their money covering them, or perhaps a toxic mix of both -- and they've been fighting it ever since.  It's long been clear that that have no idea why a mandate was essential.  Because, who knew that health care was so complicated?

As is well known, the Republicans voted at least a zillion times to repeal the ACA while Obama was president.  Finally, yesterday, under the caring leadership of our current president, the Republican-led House passed a repeal-and-replace bill that would essentially eliminate protection for people with pre-existing conditions, as well as the requirement that healthy people purchase insurance.  And, in an ugly and cynical move that makes abundantly clear the racist and other lies behind this bill, they voted to exempt themselves from its new constraints (of course, because they're the good guys!).

This bill is bad medicine.  But that's irrelevant to Republicans and their supporters.  It's not meant to be much more than a tax cut for the rich (protecting wealth being the only core tenet of that party). And a thumb in the eye of anyone who benefitted from the ACA; the poor, the sick, and the Democrats.  It will definitely be a money saver, when 24 million people lose coverage, and then die of things that those with money don't have to die of.  As Jimmy Kimmel said in his emotional defense of insurance for all.

And this is what brings us back to eugenics.  Who needs the kind of very expensive, targeted precision promised by knowledge of genes to cherrypick those who should live and those who should die?  Let's just take away access to medical care from all of Them.  And make our country great for the oligarchs again.

Replacing the Affordable Care Act -- what's so complicated?

Nobody knew health care could be so complicated? Er, except everybody but Mr Trump.  And yes, it's a huge behemoth of a system, but the devil is in the detail.  It's when you throw in all the special interests, political considerations, back-scratching, etc. that it quickly gets complicated.  But before all that happens, there are only three basic choices when it comes to providing medical insurance, and they are easy to grasp.  Choosing among them, though, has become much more of a political choice than an unloaded purely economic one.

Here's what we had before the Affordable Care Act (ACA): private insurance, either from one's employer or purchased individually.  For this to work, of course, just as any other business, insurance companies must make a profit, and that's harder when customers get sick; purchasers actually using their insurance isn't good for the bottom line.  That's why there's so much talk about people with "pre-existing conditions".  These are people who insurers know will cost them money and that's why people with "pre-existing conditions" were essentially uninsurable before the ACA, except as members of large employee pools comprised primarily of healthy people who had to buy in as a condition of their employment.  And that's why insurance companies used to charge women, older people, smokers, and so on more; they were more likely to cost money.  And that's why insurance companies also had policies such as lifetime caps on benefits.  To stay in business, insurers have to make a profit.  It's their reason for being.  This system can work well for healthy people and insurance companies.

The second option is something like the ACA, where everyone, pre-existing condition or not, can buy insurance -- an appropriate thing to point out on Rare Disease Day 2017.  As with auto  insurance, the only way this is financially viable is if everyone is required to buy in; just as good drivers subsidize unsafe drivers, healthy people subsidize people more likely to use healthy insurance.  Thus, the hated "mandate", the requirement that everyone buy in or be penalized on their taxes.  Many detractors of the ACA believe the mandate can simply be eliminated, that a replacement for the ACA can cover as many people, as cheaply, without one.  But, that's impossible. This is the same kind of privitized system that has worked without major snags for many years in Switzerland, for example. There, insurance is compulsory, and insurance companies must offer a basic plan which they aren't allowed to profit from although people can purchase bells and whistles, which is how the insurers make a profit.

The third option is the public option, often these days described as Medicare for all.  Government-supplied health insurance, paid for by tax dollars.  It's cheaper than the first two options in large part because it's non-profit, and the infrastructure required by private insurers to validate or deny claims doesn't exist.  National health has worked well in many rich countries for decades, keeping costs down and providing access to medical care to all.

And that's it.  There's no other "terrific" "cheaper" alternative anyone has thought of that can replace the ACA. The only options are a system that's totally private; something like the ACA with its mandate; and national health.  Unfortunately, this wasn't very well explained when President Obama was working on the Affordable Care Act, and it's not being explained now.  The Republicans in control of Congress aren't going to give us national health; and while it seems that many of them would be happy going back to what we used to have before the ACA, opinion polls are showing that people are less and less happy with that option.  Will Trumpcare be Obamacare renamed, then?  We'll have to wait and see.  

In any case, whatever system we adopt, we've still got problems.  Although the rising cost of medical care in the United States has slowed some with the ACA, at almost 18% of GDP health care spending here is the most expensive in the world, far exceeding that of any other high-income country, most of which have national health care (e.g., source).  In part it's because of the high cost of medical care, the higher use of expensive technology (e.g., MRI's, mammograms and C sections) and the exorbitant cost of pharmaceuticals.  And this is even with limitations imposed by insurance companies to control costs.  In addition, the cost of individual premiums has soared for people who aren't eligible for government subsidies to help cover the cost of insurance, in part, because fewer healthy people have purchased insurance than companies anticipated.  And deductibles and co-pays have risen sharply.  Insurance companies still have to turn a profit to stay in the health insurance marketplace.

Source

And, all this spending hasn't made us healthier than people in countries that spend even considerably less.

Source

So,  even if Trumpcare is as terrific and as cheap as we've been promised, it's hard to see how it will cut the high cost of medical care, and make us a healthier nation.  That is complicated, especially when private profit, rather than public health, is its fundamental basis.