Can a replacement improve upon the Affordable Care Act?

It is generally agreed that American people want three things from healthcare reform: increased access to health care, better quality of care, and slower growth of costs.

But, economic theory suggests that increased access to a higher quality of care costs more money, thus making the simultaneous attainment of all three goals exceedingly difficult, if not impossible.

Former President Obama’s Affordable Care Act (ACA), or ObamaCare, focused on increasing access to care by expanding insurance coverage to the previously uninsured and on providing better protection for people with preexisting conditions.

To improve the quality of care and patient experiences with care, ObamaCare also initiated pilot programs to reform—for example, how to provide patient-centered primary care and how physicians and hospitals are paid. However, it failed to hold the cost of health insurance down for those who gained coverage through the newly-established health insurance exchanges.

Since taking office, President Trump, along with Congressional Republicans, has begun to dismantle ACA, vowing to replace it with something better and less expensive. Without details on what this “something better” will look like, it begs the question of whether providing great health care for much less money can actually be done.

Democrats have traditionally focused on coverage expansion to help low-income and other vulnerable groups gain health insurance. This expansionary impulse reflects their belief that health care is a basic human right and the extra money spent on health care is a good investment from both the perspectives of social solidarity and population health.

Republicans, on the other hand, tend to place a greater focus on curbing health spending than on expanding insurance coverage. This aversion to using the government’s power to tax and regulate reflects their distrust of the government and unflinching faith in the market as an economic mechanism for providing goods and services, including health care.

Many of the political and ideological differences and disagreements on health care can be resolved, or at least lessened, if we can somehow slow the growth of health spending without sacrificing quality and quantity of care. In reality, can this be done?

There are many ways to reduce spending, but they all require unpleasant trade offs and sacrifices. For example, insurers can ask consumers to pay higher deductibles and copays, thus increasing patients’ out-of-pocket payments. Cost-sharing is also known for causing patients to skip necessary services or cut back their use of valuable pharmaceuticals. Insurers can also reduce costs by bringing back annual and lifetime limits on how much care is available to the insured.

Other cost-saving measures include restricting patients to narrower physician networks that ask consumers to pay more when they see an out-ofnetwork provider and setting insurance premiums based on consumers’ age, health status, and claim history in much the same way auto insurance companies price their policies.

Finally, the federal government can roll back the pre-existing condition protection to allow insurance companies to deny coverage for certain medical conditions or deny coverage altogether.

Widespread dissatisfaction with these cost-saving measures was part of the reason for the American people’s demand for national healthcare reform. We will be moving backward by bringing back these unpleasant and user-unfriendly insurance practices.

Economic analyses of most of the leading Republican plans, particularly those sponsored or endorsed by House and Senate leadership, have concluded that millions of the newly-insured will lose insurance coverage. Millions are also likely to receive skimpier and more meager coverage than what they have now.

Many health economists have also concluded that the much-touted market-based strategies, including those allowing insurance companies to sell insurance across state lines, turning Medicaid into block grants, and replacing the ObamaCare subsidies for buying insurance with annual tax credits for those who file a federal individual tax return, will not be the magic bullet .

Republicans won an impressive election victory to win control of the White House, the Senate, and the House. They now have the burden of delivering what they have promised— to cover at least as many people as the previous administration did while slowing down the growth of health costs.

If this cannot be done, we need to know what sacrifices we must make and what trade offs we must accept. Americans are rational and reasonable, and they can handle the truth.

Dr. Cyril F. Chang is a professor of economics in the Fogelman College of Business and Economics at the University of Memphis. The views expressed here are solely his and do not necessarily represent those of his employer.