Healthcare is the most important issue in our country at the moment, because the fate of coverage for millions of Americans hangs in the balance. It is definitely safer now that Collins, Murkowski and McCain voted against the repeal of the Affordable Care Act, but Trump does have the power to suffocate the ACA by withholding state funds.

There is only one solution now in this country and that is a single-payer system. It is what Obama (and others as far back as Teddy Roosevelt) wanted in the first place.

The mandate means there is a penalty for not buying coverage if you are eligible. The penalty is relatively small compared to the cost of coverage. This means that even with the mandate, there are still millions without coverage.

The problem with the penalty is that if it is too small it won’t work and if it is too big, it will become unpopular and that means losing votes.

There is no way that Obama and his team didn’t know that the mandate was going to fail like a band-aid covering a deep wound, but that combined with tax credits was the best they were able to accomplish given the opposition. There is also no way that they didn’t know that abolishing pre-existing conditions would also force the insurance companies to raise their premiums.

Am I trying to say that they wanted this to happen?

Not exactly. It was a killer series of chess moves though. If the mandate is not strong enough, too many of the healthiest Americans would choose not to have coverage. That means that the people choosing coverage are the ones that need it most. That means that insurance companies wouldn’t be able to control costs the way they did when they could choose not to offer coverage to people with pre-existing conditions. That is why, for example, my family plan was supposed to increase from $1200 to $1700 a month starting in 2017! The only reason BCBS would raise premiums that much is because their pool of insured has changed against their will.

Republicans wanted to get rid of the mandate, but that couldn’t happen without getting rid of pre-existing conditions as well and that would be wildly unpopular across party lines.

The only ways to fix this dilemma are to revert back to pre-ACA days, which would mean millions would lose their coverage, or for the government to drastically increase the penalty related to the mandate so the pool of insured becomes sufficiently balanced for the insurance companies to be able to lower their premiums, risking widespread unpopularity due to what would be perceived as excessively punitive measures, or to create a single-payer system for all. 

The Republican tax credit proposal is putting lipstick on a pig. It serves the same purpose as the mandate when it comes to incentivizing people to buy coverage, but it is inherently limited and flawed on its own. Without the mandate, it would mean even more people choosing not to have coverage.

The reason that this is untenable is that when people in the uninsured pool get sick, they still go to hospitals and rack up huge bills that they cannot pay. The hospitals have to do something to recuperate their losses so they raise their fees to the people that have insurance. The insurance companies have to recuperate their losses so they raise their premiums.

There is no going back. There is only one viable option moving forward and it is not for 22+ million people to lose their coverage. The Republicans had 7 years to come up with an alternative and vowed to repeal and replace the ACA, but they didn’t come up with anything.

Anyone that drives a car must have insurance. The fact that everyone must have car insurance is precisely what allows insurers to keep their premiums low. It’s just a given.

The resistance to universal healthcare is crumbling as the alternatives continue to implode. The time is nigh.


David B. Younger, Ph.D. is the creator of Love After Kids, for couples that have grown apart since having children. He is a clinical psychologist and couples therapist with a web-based private practice and lives in Austin, Texas with his wife, 12-year-old son, 3-year-old daughter and 5-year-old toy poodle.