American health care reform under the Republicans: three scenarios

Once again I detour into politics.  It’s for a good reason, I assure you.

Today the United States Senate Republicans have issued their own health care reform proposal, the ‘‘Better Care Reconciliation Act of 2017’’.  Finally shared in public after weeks of secrecy, it undoes chunks of the Affordable Care Act, allowing senior medical charges to rise more sharply, removing the insurance purchase mandate, ending the employer mandate, eventually reducing support for Medicaid, ending the tax increases on the wealthy, etc.  It’s pretty similar to the House bill.

If it or some closely related version becomes law, as seems likely, a good number of Americans will be furious.  Some number will see their health care coverage reduced, leading to a potential humanitarian disaster.

For my business, for my family, this is bad news.

But I’m going to hold back on outrage in this post.  I’ll also refrain from Congressional analysis.  Instead I’d like to contemplate the unfolding legislation while wearing my futurist hat.  How might this Republican move to rewrite health care funding play out over the next one to five years?

Much depends on how Americans as a whole respond.  Each scenario that follows is based on a different type of aggregate attitude, from resignation to creativity to rebellion.  I’m drawing on recent American politics, along with insights from other countries.

I: Kleptocracy? Meh.

We could resign ourselves to a worsened state of affairs.

Outrage could sputter.  The Republicans control the House, Senate, and White House, not to mention a majority of state governorships,  after all, and are capable of solid party discipline.  They could simply see the law into implementation without major obstacles.  Media coverage might put a lid on things – after all, this is complex, non-sexy stuff that tv “news” struggles to understand, much less represent.  The Republicans could do a good job of selling the new health care law, possibly using their established playbook: “BetterCare” won’t interfere with the patient-doctor relationship; deserving and good people will be spared problems; this is just a technical tweak; Obamacare was terrible; etc.

Maybe Democrats split over those wanting to protect Obamacare (call it the Clinton wing) versus others seeking single payer or Medicare for all (the Warren/Sanders faction).  That schism prevents them from organizing effectively.

There’s an awful lot of money involved, too, from Big Pharma to medical insurance to the AMA.  That money historically has the capability to get things done, including influencing not only legislators but media coverage.

Americans have come to terms with this state of affairs, accepting a kind of plutocracy or oligarchy.  It took decades for the old Gilded Age to fall under new management.  We could easily be in an earlier state of that developmental arc now.

Outside the US, the Panama Papers revealed a widespread pattern of corruption by government officials and other leaders.  This revelation powered many political responses, but a good number of the politicians survived or returned to power.  Humans, in turns out, can live under the rule of big money quite easily, or without effective demur.  Americans could follow suit.

What might this look like in five years?  By 2022 fewer Americans have health care than did in 2017.  A good number have some coverage, but at lower quality.  Most just got on with their lives, working hard, getting by.  Only wonks and history nerds talk about Obamacare.

In 2022 a large number of us think the medically un(der)covered deserve their status, because those people aren’t willing to work hard, or are stupid, or of a lesser race, or are probably immigrants, or criminals.  When Medicare fundings declines, there are few protests in the media or government.

Abortions will be less available (legally), and family planning is what wealthier people do, as a sign of character.

II: Medical System D

Instead of going along, we could build a parallel health care funding and provision system.

System D is French slang for the underground economy, one which avoids taxes and surveillance.  It describes the ingenious poor, putting stuff together from desperation or aspiration.

Imagine Americans turning system D on health care financing.  We could go abroad for procedures and drugs in order to save money.  Some of us do that now; imagine a much larger number.  Border towns become medical trading marts, and not always for cash.  Travelers routinely bring back pharma goodies for family and friends.  The internet hums with medical trade, licit and il-.  And some may simply leave the country, as wisekris points out:

or just migrate.

— Kris Wise – @wisekris.bsky.social (@wisekris) June 23, 2017

We could expand our use of alternative medicines and treatments, from acupuncture to aromatherapy.  Botanicas will become more popular, as will herbals.  Where marijuana is still illegal (cough Vermont cough) people will continue to grow and use it.  Newly rediscovered or invented folk remedies and ancient treatments will crop up, become fads, or get rebranded by Gwynneth Paltrow.

Some medical professionals will moonlight in system D.  Imagine nurses smuggling pills to those who can’t afford “BetterCare”, general practitioners doing quiet home visits for barter or bitcoin, pharmacists pooling samples to supply elderly relatives no longer fully covered by Medicare.

American tinkering should produce more DIY solutions to health care problems.  We can already see hints of this with electrical brain stimulation, pleasantly wacky ASMR, and Thync.  Our era adores startups, including bogus ones, so we should expect more.  Wait for an enterprising grad student to exchange experimental nanomedicines for barter.

The backlash to system D could well be ferocious.  The AMA might crack down on its members, as would the APA.  Congress could tighten patent regulations, pass laws blocking importation of medicines, add tariffs to medical tourists, crack down on medical activity online, or ramp up regulations of alternative medicines.  If enough people shift enough purchasing power to system D, “Better Care”-aligned medical providers and/or insurance companies could increase their prices.  That, in turn, could nudge more people to system D.

By 2022 there could be a seesaw struggle between system D and the legit world of “BetterCare”.  It might acculturate into popular songs, folklore, and stories.  Imagine a swiftly-changing corpus of codes, signs, and countersigns to access system D.  We might watch a tv series about heroic doctors working on gorgeous, celebrity patients, while sending bitcoin to a traveling relative so they can buy more Cuban insulin.

III: Revolt

Alternatively we could explode.

We already have the seeds of unrest in 2017, with the anti-Trump #Resistance meme, multiple national marches, and especially those rebellious town hall meetings.  There is rising tension over increased deportations, which could grow into open unrest.  Trump’s poll numbers are very low for a first-year president, as are survey ratings for the House health care bill.

Listen to how Bernie Sanders describes “Better Care” in an email I just received:

They call it a health care bill, but how can it be a health care bill when it throws 23 million people off of insurance, cuts $834 billion from Medicaid, and defunds Planned Parenthood? God knows what the implication of this legislation will be on our children, the elderly, and those of us with chronic illnesses.

It is literally insane. I have a hard time understanding what kind of world these guys are living in sometimes.

This is a bill that impacts a sixth of the American economy and touches every single American family.

The big money factor could really motivate the Democratic Sanders/Warren/left faction into public actions.  Recall the energies they demonstrated during the Democratic primary; will they be even more active when faced with a more open threat?

This new law could push even more of us into the streets.  Health care issues strike deeply into many of us.  Seniors generally consume more health care *and* both vote and donate more than younger folks.  The threat of losing medical coverage for oneself, or for loved ones, could easily drive people to protest, march, express themselves, or cross into illegal behaviors.

Indeed, we’re primed to pay great attention to every act of violence or insurgency.  Media attention slathers itself on each outrage, shooting, or especially terrorist strike.  Politicians position themselves carefully for maximum advantage.  Partisans and party activists pounce on each opportunity.  In short, we’re almost panting for violent unrest.

I don’t mean that sarcastically.  I’m not arguing that media cause behavior, but that attention can magnify small acts (in a country of 320 million) into enormous events, sometimes with political consequences.  And there are many opportunities for individuals to, say, shoot at Senators in a country loaded with firearms, polarized into warring political camps, and terrified of health care horrors from sudden injury to agonizing death to interminable pain.

And it’s summer.  Depending on where you are and microclimates, it could be riot weather.

Short of violence, or in parallel with it, there’s a major opportunity for nonviolent political action.  Political pressure blocked the first House health care bill; if scaled up further, could it actually block Senate passage, or reconciliation votes in either House?  Imagine people marching in the streets at late 1960s levels, or senior citizens conducting guerrilla theater actions in statehouses, or Senators publicly receiving (or getting pied by) cremated ashes of people who died without health care.  Done right, such an insurgency could peel off enough Republican Senators and Representatives to vitiate a majority and stall the bill.

That’s for 2017.  What would it mean for 2022 if America enters something like civil unrest this year?  I’m going to hold off on this one for now, because there are too many possibilities for an already long post.

Revolt, System D, and Kleptocracy, Meh: which do you think is most likely to occur?

(thanks to my wife and various Facebook friends for thrashing out ideas; piggy bank photo by 401kcalculator.org; “Life before National Health Service (NHS)” photo by Paul Townsend)

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