Donald Trump has promised to repeal and replace Obamacare.  The Senate and House have begun the effort to defund the legislation via the budgetary and reconciliation process, where only 51 Senate votes are required.  However, lost in all this minutia is the fact that Obama has succeeded in altering the discussion on health care.  This change to federalism has legitimatized a role for the national government in health care for all citizens.  This has further weakened the Tenth Amendment.  This is his legacy.

The narrative is no longer whether the federal government should be involved in health care for all people, but to what extent.  Since over 12 million people now receive health insurance via the federal Obamacare portal, there is reluctance in Washington to eliminate a federal role for providing health care insurance.

Repeal through reconciliation will allow the elimination of the many Obamacare taxes and rules stifling employment.  Providing the coverage for the subsidized insured persons is more problematic.  Presently there are seven similar competing Republican replacement plans.  It is time to coalesce behind one proposal that can muster the necessary Senate votes.

The premium cost increase temperance quoted by the president does not include the federal taxpayer subsidies that moderated the overall numbers.  Within the private insurance marketplace, the rate of increase of premiums has accelerated.  This is in part due to the many mandates created by the Department of Health and Human Services through the 27,000 pages of regulations.  Obamacare has accelerated the consolidation of providers from private practice settings to hospital-based management, further eroding the quality of care.

Replacement legislation is more complex, as it requires compromises that will allow at least eight Democrats to block a filibuster (which requires 60 votes).  Some Republicans such as Senator Rand Paul want a concurrent replacement with reasonable budgetary constraints, adding to the complexity.  In the House, the Freedom Caucus is reluctant to support any legislation that explodes the budget or expands the federal reach.  One such compromise might include national government negotiation with pharmaceutical industry companies over drug costs under Medicare.

The Great Society programs of the Johnson presidency established a role for the federal government in providing health care for seniors and the poor through Medicare and Medicaid.  Costs for these programs have escalated well beyond any imagined amount when these programs were established.  The same is true of Obamacare.  Any replacement must have a different basis to be sustainable.  Elimination of the individual mandate creates further issues for spreading the costs.

Rand Paul has argued for a plan that allows younger and healthier people to purchase catastrophic health care policies with lower premiums and higher deductibles.  This is a reasonable proposal, as it eliminates the many mandates of Obamacare; further, it can spread the costs among more people.  Most Republican offerings allow for purchase of policies across state lines, increasing competition and lowering costs.  This proposal must consider the right of states to regulate insurance to garner enough votes in the Senate.

Any plan will likely allow family coverage up to age 26.  This might include some rate increase for the added costs.  The issue of pre-existing conditions is thornier.  Paul has argued for small businesses to join large associations to negotiate better conditions and lower premiums, allowing this cost (elimination of pre-existing conditions) to be less of an issue.  This is a failure of Obamacare via unexpected consequences resulting from reluctance of healthy people to enroll.

For most people, the health care industry was far more manageable prior to Obamacare.  In less than eight years, the federal government has caused higher costs, longer wait times to see physicians, and less personal care.  Any effort to reform the industry should re-emphasize the private insurance system.  In this sector will be the greatest opportunity for innovation and cost containment.

In one week, the Trump administration will take power.  We can only hope Democrats will choose to participate in fixing the failing health care payment system.  Politics will intervene, making it difficult for minority leader Senator Schumer to encourage a replacement to Obamacare.

We missed an opportunity to reverse Obamacare in 2012, when millions of Republicans stayed home and refused to vote for Mitt Romney.  Donald Trump was elected as the voters rejected conventional politics.  Schumer and many swing-state Democrat senators up for re-election in 2018 may decide that real reform is politically beneficial.  Trump, Speaker Ryan, and Majority Leader McConnell will require all their negotiating skills for success.  In the end, Obama has won the principle, and this is his legacy.

Dr. Warner practices dentistry in New York State.