EDITORIAL: Swapping Trumpcare for Obamacare: GOP should be careful

Jan. 06--President-elect Donald Trump and most congressional Republicans are eager to repeal the Affordable Care Act and replace it with their own overhaul of the health-care system. The San Diego Union-Tribune Editorial Board welcomes this resolve. Former President Clinton famously called the 2010 law "the craziest thing in the world" last year because it leaves many Americans "with their premiums doubled and their coverage cut in half."

Nevertheless, the overhaul of the ACA must be done with extreme care. Trumpcare must not be as flawed and frustrating as Obamacare.

Identifying the biggest flaw in Obamacare is the easy part. Yes, the law has helped 20 million people get health care. But California's successes with its state-run version of ACA haven't been replicated in states with far fewer residents and less or no insurer competition. In the 39 states that use the federal health insurance marketplace, it's been expensive for those without employer-provided insurance who are not eligible for government subsidies. The policies can have the triple whammy of costly premiums, high deductibles and harsh co-pays.

Just as many ACA critics predicted long ago, it is well on its way to creating a health insurance "death spiral" in many states. Fewer and fewer middle-income and affluent people sign up, meaning mostly only subsidized individuals enroll, meaning states have to charge the unsubsidized enrollees even more. This phenomenon is evident in the Obama administration's October forecast that ACA premiums would go up by an average of 25 percent in the 39 states in 2017. When more than 80 percent of ACA enrollees get subsidies, the relatively few enrollees who don't are going to get hammered.

But finding an approach that is superior to both Obamacare and the cruel old days of broad indifference to millions of families without health insurance isn't easy. We welcome Trump's embrace of the ACA provision allowing children to remain on their parents' policies until they are 26 and his support for trying to increase competition among insurers to bring down premium costs. Yet the central change proposed by Rep. Tom Price, R-Georgia -- the doctor who is Trump's choice to be secretary of health and human services -- is no solution to anything. The idea of providing tax credits to poor families to help them buy coverage directly from insurers is a feel-good soundbite in a nation in which 45 percent of households pay no federal income taxes.

So what is America to do? A smart option is to copy what works in nations that have effective but less expensive health care systems. Some European nations have strictly enforced individual health insurance mandates, increasing the risk pool and limiting the "free rider" problem. Some have basic government health care and specialized care through private insurers. But given the anti-government, anti-regulation ethos of the modern GOP, a European copy is highly unlikely to be embraced.

Perhaps the most promising outcome is that technology comes to the rescue, disrupting health care by driving down medical costs and increasing efficiency as it has in so many other fields. A promising era looms in which body-monitoring technology combined with Big Data insights into medicine can catch early-warning signs of declining health. IBM software, for one, grows steadily more adept at evaluating radiology images.

But the most likely outcome is a return to the cruel old days. We hope that doesn't happen -- because while Obamacare has disappointed many, its enactment was a response to real problems.

Soon the GOP will own them -- or the solution.

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