Senator Susan Collins of Maine and Senator Bill Cassidy of Louisiana, two very different politicians, plan to unveil their proposal for replacing Obamacare on Monday.  This combination of sponsors gives hope that a compromise will be possible with Senator Charles Schumer of New York, the minority leader.  This is necessary since the Democrats can filibuster any replacement plan.  Budgetary reconciliation process can allow removal of Obamacare funding via a simple majority but does not allow for replacement legislation.  Replacement legislation is required to remove the negative impact for Republicans and to the 13 million users of the federal exchanges resulting from defunding alone.

Susan Collins is a moderately liberal Republican who has crossed the aisle to work with Democrats on many social issues.  She has spent most of her adult life in government positions.  She has relations with more conservative Democrats as a result.  She has proven to be a smart politician who has been re-elected by wide margins.  She did not vote for Obamacare.  Most importantly, she did not support Trump for the presidency, despite being the senior Republican senator from a New England state.

Bill Cassidy, a conservative Republican, was a practicing physician who worked in a state hospital.  He is a strong opponent of Obamacare who has concerns about the long-term financial stability of the medical system.  He was elected in 2014, defeating Mary Landrieu (D), who had supported Obamacare.  He brings an understanding of medicine and political acumen.  He can help unify the slightly different plans within the Senate, hopefully gaining Rand Paul’s support.  Paul, a libertarian Republican, seeks a plan that will allow more personal choices while controlling costs.  Certainly any compromises will require the support of the medical community within the political world.

The early thinking for this plan may include the ability for states to choose to continue with Obamacare but with funds limited by block granting.  The same will occur in the health care system for the poor, Medicaid, according to Kellyanne Conway.  Block grants limit the federal costs and allow states to innovate.  Many of the larger liberal states would resist this, as it limits increases in spending and, they argue, care.  However, if the inflation adjustments are handled correctly, this approach empowers enough states to create alternative delivery systems.

President Trump (that sounds so nice) wants a plan that can cover the many people now on Obamacare.  His HHS secretary-designate, Tom Price (Republican representative from Georgia), is a physician who proposed an alternate plan in 2015, which emphasized health savings accounts as a method of gaining more market participation by patients.  Cost controls require greater financial participation in decisions by consumers.

Removal of the individual mandate will remove the tax penalty that helped pay for the Affordable Care Act.  Forty years ago, patients paid directly for health care costs, close to 50%, but today that amount is less than 15%, displacing the onus for health care costs to third parties.  Additionally, most of the costs in any year are attributable to fewer than 10% of the patients.  This is most critical at the end of life.  These issues must be addressed, or any plan will ultimately fail.

Trump has started the process by executive order.  This sends the message to Congress that it must move quickly and simultaneously repeal and replace the unaffordable law.  The press will minimize any progress toward this end.  Quiet negotiations will be more successful.

Affordable care is sustainable only through market forces. Third parties such as the government and insurance companies distort this process.  They are a necessary evil.  Any plan must focus on consumers’ desire to control expenses, as they do at the grocery store.