Back when insurers COULD discriminate against pre-existing conditions, I had a thought. If we buy a car and find out it's actually terrible, we can buy a different car. But if we buy health insurance and find out actually terrible (by getting sick, needing it, and finding it wanting), other insurers would be unwilling to take us on. That would be like buying a Chevy, later deciding you wanted a Honda, but the Honda dealer won't sell you a car because you're a high-risk buyer.
Josh, I studied health care policy and health insurance at one point, and have tried to follow the issues over the last 25 or 30 years. Your perspective is a fresh one for me. You have cut to the chase of why the GOP can't come up with a plan.
I would only add perhaps another point or half point, which is that the GOP strongly prefers that health insurance be tied to employment. That's not compatible with everyone being in a risk pool that is big enough to provide much coverage. That doesn't just affect people who are unemployed, but also self-employed, gig workers who receive no benefits, people working for very small companies, etc.
Also, I think there is a slightly misleading aspect to saying that poor people (and people with disabilities) get free insurance through Medicaid. Medicaid reimburses providers at much lower rates than Medicare and (most? much of?) private insurance. Consequently, many doctors and clinics that accept Medicare patients and private insurance do not accept Medicaid patients. This would especially limit access to specialists.
Nonetheless, I don't want to distract from your analysis, which is so excellent.
> the GOP strongly prefers that health insurance be tied to employment
Can you say more about this please? Is this an outright preference (like, they really want employers in the loop), or is it just that they prefer this arrangement to ones where the government is more heavily involved? So would they go for an option where insurance was totally private (either you can afford it or you miss out) but did not involve employers?
What I mean is, they want to see access to insurance provided by private insurance companies AND by one's employer, as a benefit of employment, or at least conditioned on employment.
The latter would be something like their push for work requirements for SNAP eligibility. Right now, I'm blanking on whether there is an exact parallel to SNAP work requirements within any federal health insurance programs, but the underlying policy preference is important to keep in mind. It's in keeping with conservative principles like personal responsibility, equality of opportunity not outcome, the belief that anyone can get ahead if they work hard, therefore poor people must be lazy and should just get off their butts, etc.
In terms of via employment, most/many Americans get their health insurance through their job. Health insurance is one of the benefits companies offer to full-time, formal employees. The employer decides on what degree of coverage it can afford to provide (negotiating this with employee unions, if necessary) and contracts with a private insurance company to provide a specific policy for its employees.
(FYI, the federal government offers not just one plan to federal employees, but a menu of different levels of plans, from various insurance companies, that employees can choose from. Employees are charged part of the cost, and, of course, plans with more generous benefits and lower deductibles cost the employee more. I don't actually remember offhand whether large private employers also do this?)
From an international perspective, America is highly unusual in the extent to which people get health insurance as an employment benefit. It's a historical fluke that health insurance developed in this way here.
During WWII, there were wage and price controls, as well as a labor shortage. Companies competing for employees figured out that they could get around wage controls by offering health insurance as a benefit. So the US developed a health insurance industry that catered to employers, and that continued after the war. I can't emphasize enough how fundamentally different our overall health care system is from the rest of the world in this regard. We're sort of geographically isolated from the rest of the world and not very aware of how other countries do healthcare, so we tend to accept this as just the way things are. And conservatives tend to view it as ideal, given the principles I mentioned above.
However, in the WWII era, health insurance wasn't very expensive because medicine was very limited in what it could do -- mainly antibiotics and basic surgery, let's say. As therapies and technologies have developed, life expectancy has been extended but it's become more and more expensive. No one can just pay out of pocket for long, companies are finding providing insurance more and more burdensome, and the structure of employment has changed so that it's harder to find jobs with benefits. Thus there was fertile ground for the ACA that didn't exist earlier, and a majority of people don't want it taken away.
Obviously, I'm oversimplifying. There is a range of views within the GOP as there is within other parties and the electorate. And our healthcare system is such a patchwork, it's hard to say anything about it without many caveats and footnotes.
Thank you for an excellent and well thought-out reply. I'm Australian so quite used to a combination of public provision and private insurance, but largely without employer involvement, so I find it very confusing.
In terms of the trilemma, I think the Republicans only want #1 and #2. No requirements to buy insurance and no large subsidies. I think they only "want" #3 because opposing it is political suicide, and each and every one of their so-called health care plans is some sort of scheme intended to pull the wool over the public's eyes so that they can do #3 without anyone catching on.
It's tiresome that Republicans are forcing us to once again debate an issue we settled more than fifteen years ago, and about which they know (or care) very little.
I think it is a misconception to believe that, prior to the ACA, health insurance companies could refuse to cover somebody because of a pre-existing condition, or could refuse to cover those pre-existing conditions. HIPAA, enacted in 1996, was the Health Insurance *Portability* and Accountability Act, and it prohibited employer plans and large group plans from discriminating against beneficiaries with pre-existing conditions. Moreover, these plans could only refuse to cover those pre-existing conditions for a year. And they couldn't refuse to cover them at all if the beneficiary could demonstrate that he/she had had continuous health insurance for a year prior.
This actually was a decent compromise between holding individuals accountable for their own coverage and not excluding beneficiaries with chronic illnesses.
This is a good point: before the ACA, there was a trend toward protecting people from being denied insurance due to pre-existing conditions. However, as you note, this applied to employer plans (with at least ten employees, I think?) and large group plans. Many Americans are self-employed or work for smaller businesses, etc., so that left many people effectively uninsured.
HIPAA was a step forward, but companies were still able to offer plans that did not cover various services and conditions, and your insurance could turn out to be not very useful. One example is pregnancy and childbirth, which insurance companies would love to avoid. Normal childbirth is not cheap; pregnancy is risky, and the complications are expensive; and neonatal intensive care for premature births is very expensive.
I remember shortly after the ACA passing older male legislators arguing they don’t need pregnancy or neonatal care (and neither do their spouses if they are older) so should be able to buy a policy without that coverage to save money. I wondered whether requiring the list of “essential health benefits” to be covered ended up being ONE factor that made insurance more expensive post ACA. I know LOTS of factors make insurance premiums expensive, and I still point to high health care prices, especially hospital services. Providers often claim they have to charge a lot because of all the uncompensated care. I don’t buy that when said by certain hospitals here in Houston.
You would think they would be a little more concerned about their grandkids or great grandkids, lol. I think that was mainly a tactic, but our legislators do tend to be so wealthy that they could self-insure, and their kids as well, most likely.
I probably should have chosen an example that affects men. In general preventive services and screenings save money as well as lives. E.g., hypertension can lead to so many expensive conditions like kidney failure. Screening for and treating hypertension is relatively cheap. There is must be an evaluation looking at the question you raise... would be interesting to find. It's hard to sort through the information on any political football issue, though.
One aspect is that before the ACA, there were a lot of junk policies out there that were cheap because they didn't cover much, or had wording that enabled companies to easily deny claims, etc. Some people saw the cost go up because they effectively didn't have health insurance before. They just hadn't happened to find that out yet.
Really interesting to read through observations on changes to health insurance over the years. I worked with a lot of it during my working years (retired in 2015).
My recall is hazy about the various new things my employer had to deal with, except for two. One of my first assignments with my new job in 1989 was to call around to see if we could get coverage for our employees. Over and over again, I heard “Automatic denial.” The other thing was to ask each year during a new enrollment period whether the insurer would cover domestic partners. I heard “no” a lot. It was great to see marriage equality and have the question finally dealt with.
Interesting . . . So was what the ACA fixed that it prohibited insurance companies from denying coverage to people buying in the individual market, whereas what you are talking about applied to employer coverage? And of course, for someone with cancer, a year without coverage is a lot of money.
I think businesses under 10 employees were not required to offer health insurance and, of course. self-employed people do not have employment based insurance. (unless through a union or other professional group, etc.). But many people fell through the cracks. I think this is what the ACA's insurance market place takes care of.
Also, the ACA set some standards for the benefits to be covered, so that people didn't get sick and then find out that their policy was worthless junk. For example, pregnancy and childbirth were often excluded. There are many other examples, and policies were often worded in such a way that coverage could easily be denied.
Thanks, I wasn't sure of the specifics, and it does vary greatly from state to state. That must be a lot of businesses exempted. And companies find ways to get around the 50 employee rule. I can't remember how it came out, but Uber drivers sued Uber because Uber classified them as contractors rather than employees in order to get out of providing benefits.
If you maintained health-insurance coverage (even when you were well), you could switch employers or switch insurance, and you'd be covered for your new cancer diagnosis without a waiting period. It was like the free(er) market version of the individual mandate: if you chose to let your coverage lapse, you could be faced with up to a year-long wait for coverage for a medical catastrophe, so there was a strong incentive not to let it lapse. Even under the ACA currently, if you choose not to sign up for insurance and then get diagnosed with cancer outside of the open-enrollment period at the end of the year, you still have to wait up to a year (until the next open-enrollment period) to be able to get insurance.
I'm not sure precisely which insurance plans were regulated by HIPAA, though I believe it regulated the plans that covered the large majority of (covered) people. The ACA added a whole lot more than just regulating the individual market - for instance, it instituted the individual mandate (for a while), premium subsidies, specification of minimum benefits for most health insurance.
The assertion that “health insurance companies couldn’t refuse to cover people due to pre existing conditions” is false. Prior to Obama care I was a mid thirties male, just off a career as a professional volleyball player, in playing shape but with several previous knee surgeries. I was blacklisted. That is companies sharing information of a single denial resulted in zero options for me to find regular insurance on the open market.
I was in better physical health than 99.9% of the population but told I was uninsurable. It was a blunt look at what actually sick Americans were facing. That system was untenable.
Flood "insurance" in many cases is not even insurance, because the risks are too predictable, and too high to be priced effectively in the private market. It is just a government subsidy.
This is a great summation of the problem of designing health insurance policy. Isn't it true that there are separate policy options to bring down the price of the underlying health care services? I think that is what Senator Cassidy and some others are thinking of--the money the feds were spending on enhanced subsidies would end in the form of payments to insurers, but people could be eligible to receive the value of the subsidy to spend on health care services. When people are incentivized to price shop for non-emergency service/routine health care, providers have to compete on quality and price. I like that idea, but want clarification that people are still expected/required to purchase a catastrophic coverage policy, violating number one above. The WaPo editorial board made the point the Dems could have done this by re-implementing the tax penalty for not buying insurance. Republicans zeroed out the tax, but what stops the Dems (when they were in power) from imposing a substantial penalty?
Mary Beth, I found this page on the essential services. It looks like it's from 2010, and it's a fact sheet, probably from some kind of archive, so I'm not certain that's how the ACA was implemented or how it is now. But it gives some idea of what the essential services are/were and the rationale.
Two things can be true at the same time: (1) some conditions will never have a cure; and (2) there is a strong incentive to only fund research into treatments that manage symptoms, but keep you sick enough to need that treatment for the rest of your life.
Good question. I am inclined to say number one--require everyone to purchase at least catastrophic coverage. And I guess since the ACA requires all plans to cover a list of essential health benefits. catastrophic coverage today just means a really high deductible?
In practice, it would depend on how exactly they define the law and regulations. I sort of feel like these services are not really covered unless they are outside the deductible. Theoretically, there may be some level of deductible where you would save so much on the premium that you could cover some of these things out of pocket. In practice, however, many people who are financially pressed just wouldn't go to the doctor unless they broke an arm, etc. So you get back to people not getting their blood pressure screened and ending up with strokes or kidney failure. ACA costs might or might not go down but Medicare would go up... It's SO complicated.
It would be a question of degree rather than completely giving up, wouldn't it? Also facing up to the fact that it's more feasible to adjust the ACA than to come up with something very different. Some of the things they've talked about would be deeply unpopular with a majority of voters.
What Romney did - and what Obama did - is actually basically what the republican plan WAS for 20+ years. It came out of The Heritage Foundation in the 70s and was first supported by Nixon. Think about it - the government pays money and forces people to buy private insurance. Sounds pretty republican. There are difference, but one basic reason the republicans don’t have an alternative is because ACA was their plan…. Your explanations are excellent!
For those who are very interested in this topic, the Bulwark just published a piece that alludes to the constraints that Josh has explained so clearly, and delves into some other aspects of the politics.
Josh, I quoted you in a comment on the Bulwark article and listed your key points (the trilemma). I couldn't figure out how to link it, sorry. I did give the article title and name of your Substack, so people ought to be able to search it out if they're on Substack.
> but you can’t tell people not to get cancer if they can’t afford to insure against the risk of continuing to have cancer.
Trump, probably: "I like the insured people who 𝘥𝘰𝘯'𝘵 get cancer"
Back when insurers COULD discriminate against pre-existing conditions, I had a thought. If we buy a car and find out it's actually terrible, we can buy a different car. But if we buy health insurance and find out actually terrible (by getting sick, needing it, and finding it wanting), other insurers would be unwilling to take us on. That would be like buying a Chevy, later deciding you wanted a Honda, but the Honda dealer won't sell you a car because you're a high-risk buyer.
That's a great analogy!
Josh, I studied health care policy and health insurance at one point, and have tried to follow the issues over the last 25 or 30 years. Your perspective is a fresh one for me. You have cut to the chase of why the GOP can't come up with a plan.
I would only add perhaps another point or half point, which is that the GOP strongly prefers that health insurance be tied to employment. That's not compatible with everyone being in a risk pool that is big enough to provide much coverage. That doesn't just affect people who are unemployed, but also self-employed, gig workers who receive no benefits, people working for very small companies, etc.
Also, I think there is a slightly misleading aspect to saying that poor people (and people with disabilities) get free insurance through Medicaid. Medicaid reimburses providers at much lower rates than Medicare and (most? much of?) private insurance. Consequently, many doctors and clinics that accept Medicare patients and private insurance do not accept Medicaid patients. This would especially limit access to specialists.
Nonetheless, I don't want to distract from your analysis, which is so excellent.
> the GOP strongly prefers that health insurance be tied to employment
Can you say more about this please? Is this an outright preference (like, they really want employers in the loop), or is it just that they prefer this arrangement to ones where the government is more heavily involved? So would they go for an option where insurance was totally private (either you can afford it or you miss out) but did not involve employers?
What I mean is, they want to see access to insurance provided by private insurance companies AND by one's employer, as a benefit of employment, or at least conditioned on employment.
The latter would be something like their push for work requirements for SNAP eligibility. Right now, I'm blanking on whether there is an exact parallel to SNAP work requirements within any federal health insurance programs, but the underlying policy preference is important to keep in mind. It's in keeping with conservative principles like personal responsibility, equality of opportunity not outcome, the belief that anyone can get ahead if they work hard, therefore poor people must be lazy and should just get off their butts, etc.
In terms of via employment, most/many Americans get their health insurance through their job. Health insurance is one of the benefits companies offer to full-time, formal employees. The employer decides on what degree of coverage it can afford to provide (negotiating this with employee unions, if necessary) and contracts with a private insurance company to provide a specific policy for its employees.
(FYI, the federal government offers not just one plan to federal employees, but a menu of different levels of plans, from various insurance companies, that employees can choose from. Employees are charged part of the cost, and, of course, plans with more generous benefits and lower deductibles cost the employee more. I don't actually remember offhand whether large private employers also do this?)
From an international perspective, America is highly unusual in the extent to which people get health insurance as an employment benefit. It's a historical fluke that health insurance developed in this way here.
During WWII, there were wage and price controls, as well as a labor shortage. Companies competing for employees figured out that they could get around wage controls by offering health insurance as a benefit. So the US developed a health insurance industry that catered to employers, and that continued after the war. I can't emphasize enough how fundamentally different our overall health care system is from the rest of the world in this regard. We're sort of geographically isolated from the rest of the world and not very aware of how other countries do healthcare, so we tend to accept this as just the way things are. And conservatives tend to view it as ideal, given the principles I mentioned above.
However, in the WWII era, health insurance wasn't very expensive because medicine was very limited in what it could do -- mainly antibiotics and basic surgery, let's say. As therapies and technologies have developed, life expectancy has been extended but it's become more and more expensive. No one can just pay out of pocket for long, companies are finding providing insurance more and more burdensome, and the structure of employment has changed so that it's harder to find jobs with benefits. Thus there was fertile ground for the ACA that didn't exist earlier, and a majority of people don't want it taken away.
Obviously, I'm oversimplifying. There is a range of views within the GOP as there is within other parties and the electorate. And our healthcare system is such a patchwork, it's hard to say anything about it without many caveats and footnotes.
Thank you for an excellent and well thought-out reply. I'm Australian so quite used to a combination of public provision and private insurance, but largely without employer involvement, so I find it very confusing.
In terms of the trilemma, I think the Republicans only want #1 and #2. No requirements to buy insurance and no large subsidies. I think they only "want" #3 because opposing it is political suicide, and each and every one of their so-called health care plans is some sort of scheme intended to pull the wool over the public's eyes so that they can do #3 without anyone catching on.
It's tiresome that Republicans are forcing us to once again debate an issue we settled more than fifteen years ago, and about which they know (or care) very little.
I think it is a misconception to believe that, prior to the ACA, health insurance companies could refuse to cover somebody because of a pre-existing condition, or could refuse to cover those pre-existing conditions. HIPAA, enacted in 1996, was the Health Insurance *Portability* and Accountability Act, and it prohibited employer plans and large group plans from discriminating against beneficiaries with pre-existing conditions. Moreover, these plans could only refuse to cover those pre-existing conditions for a year. And they couldn't refuse to cover them at all if the beneficiary could demonstrate that he/she had had continuous health insurance for a year prior.
This actually was a decent compromise between holding individuals accountable for their own coverage and not excluding beneficiaries with chronic illnesses.
This is a good point: before the ACA, there was a trend toward protecting people from being denied insurance due to pre-existing conditions. However, as you note, this applied to employer plans (with at least ten employees, I think?) and large group plans. Many Americans are self-employed or work for smaller businesses, etc., so that left many people effectively uninsured.
HIPAA was a step forward, but companies were still able to offer plans that did not cover various services and conditions, and your insurance could turn out to be not very useful. One example is pregnancy and childbirth, which insurance companies would love to avoid. Normal childbirth is not cheap; pregnancy is risky, and the complications are expensive; and neonatal intensive care for premature births is very expensive.
I remember shortly after the ACA passing older male legislators arguing they don’t need pregnancy or neonatal care (and neither do their spouses if they are older) so should be able to buy a policy without that coverage to save money. I wondered whether requiring the list of “essential health benefits” to be covered ended up being ONE factor that made insurance more expensive post ACA. I know LOTS of factors make insurance premiums expensive, and I still point to high health care prices, especially hospital services. Providers often claim they have to charge a lot because of all the uncompensated care. I don’t buy that when said by certain hospitals here in Houston.
You would think they would be a little more concerned about their grandkids or great grandkids, lol. I think that was mainly a tactic, but our legislators do tend to be so wealthy that they could self-insure, and their kids as well, most likely.
I probably should have chosen an example that affects men. In general preventive services and screenings save money as well as lives. E.g., hypertension can lead to so many expensive conditions like kidney failure. Screening for and treating hypertension is relatively cheap. There is must be an evaluation looking at the question you raise... would be interesting to find. It's hard to sort through the information on any political football issue, though.
One aspect is that before the ACA, there were a lot of junk policies out there that were cheap because they didn't cover much, or had wording that enabled companies to easily deny claims, etc. Some people saw the cost go up because they effectively didn't have health insurance before. They just hadn't happened to find that out yet.
Really interesting to read through observations on changes to health insurance over the years. I worked with a lot of it during my working years (retired in 2015).
My recall is hazy about the various new things my employer had to deal with, except for two. One of my first assignments with my new job in 1989 was to call around to see if we could get coverage for our employees. Over and over again, I heard “Automatic denial.” The other thing was to ask each year during a new enrollment period whether the insurer would cover domestic partners. I heard “no” a lot. It was great to see marriage equality and have the question finally dealt with.
Interesting . . . So was what the ACA fixed that it prohibited insurance companies from denying coverage to people buying in the individual market, whereas what you are talking about applied to employer coverage? And of course, for someone with cancer, a year without coverage is a lot of money.
I think businesses under 10 employees were not required to offer health insurance and, of course. self-employed people do not have employment based insurance. (unless through a union or other professional group, etc.). But many people fell through the cracks. I think this is what the ACA's insurance market place takes care of.
Also, the ACA set some standards for the benefits to be covered, so that people didn't get sick and then find out that their policy was worthless junk. For example, pregnancy and childbirth were often excluded. There are many other examples, and policies were often worded in such a way that coverage could easily be denied.
In CA, businesses with under 50 full time equivalent employees are not required to offer coverage.
Thanks, I wasn't sure of the specifics, and it does vary greatly from state to state. That must be a lot of businesses exempted. And companies find ways to get around the 50 employee rule. I can't remember how it came out, but Uber drivers sued Uber because Uber classified them as contractors rather than employees in order to get out of providing benefits.
If you maintained health-insurance coverage (even when you were well), you could switch employers or switch insurance, and you'd be covered for your new cancer diagnosis without a waiting period. It was like the free(er) market version of the individual mandate: if you chose to let your coverage lapse, you could be faced with up to a year-long wait for coverage for a medical catastrophe, so there was a strong incentive not to let it lapse. Even under the ACA currently, if you choose not to sign up for insurance and then get diagnosed with cancer outside of the open-enrollment period at the end of the year, you still have to wait up to a year (until the next open-enrollment period) to be able to get insurance.
I'm not sure precisely which insurance plans were regulated by HIPAA, though I believe it regulated the plans that covered the large majority of (covered) people. The ACA added a whole lot more than just regulating the individual market - for instance, it instituted the individual mandate (for a while), premium subsidies, specification of minimum benefits for most health insurance.
The assertion that “health insurance companies couldn’t refuse to cover people due to pre existing conditions” is false. Prior to Obama care I was a mid thirties male, just off a career as a professional volleyball player, in playing shape but with several previous knee surgeries. I was blacklisted. That is companies sharing information of a single denial resulted in zero options for me to find regular insurance on the open market.
I was in better physical health than 99.9% of the population but told I was uninsurable. It was a blunt look at what actually sick Americans were facing. That system was untenable.
Which works great, but only if you are in an employer or large group plan.
Flood "insurance" in many cases is not even insurance, because the risks are too predictable, and too high to be priced effectively in the private market. It is just a government subsidy.
This is a great summation of the problem of designing health insurance policy. Isn't it true that there are separate policy options to bring down the price of the underlying health care services? I think that is what Senator Cassidy and some others are thinking of--the money the feds were spending on enhanced subsidies would end in the form of payments to insurers, but people could be eligible to receive the value of the subsidy to spend on health care services. When people are incentivized to price shop for non-emergency service/routine health care, providers have to compete on quality and price. I like that idea, but want clarification that people are still expected/required to purchase a catastrophic coverage policy, violating number one above. The WaPo editorial board made the point the Dems could have done this by re-implementing the tax penalty for not buying insurance. Republicans zeroed out the tax, but what stops the Dems (when they were in power) from imposing a substantial penalty?
Mary Beth, I found this page on the essential services. It looks like it's from 2010, and it's a fact sheet, probably from some kind of archive, so I'm not certain that's how the ACA was implemented or how it is now. But it gives some idea of what the essential services are/were and the rationale.
https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/preventive-care-background
The unsolvable part of healthcare is that, for the last fifty years, all of the R&D investment has gone into keeping you alive, but not cured.
that is a slogan without meaning.
What is cured biologically if one has a congenital condition, what is cured if one developed a cancer that has genetic ties?
It is simply not yet in the mastery of cell biological science and medical research is not TV science, magical.
Two things can be true at the same time: (1) some conditions will never have a cure; and (2) there is a strong incentive to only fund research into treatments that manage symptoms, but keep you sick enough to need that treatment for the rest of your life.
Which one *should* they give up on?
Good question. I am inclined to say number one--require everyone to purchase at least catastrophic coverage. And I guess since the ACA requires all plans to cover a list of essential health benefits. catastrophic coverage today just means a really high deductible?
Fascinating question!
In practice, it would depend on how exactly they define the law and regulations. I sort of feel like these services are not really covered unless they are outside the deductible. Theoretically, there may be some level of deductible where you would save so much on the premium that you could cover some of these things out of pocket. In practice, however, many people who are financially pressed just wouldn't go to the doctor unless they broke an arm, etc. So you get back to people not getting their blood pressure screened and ending up with strokes or kidney failure. ACA costs might or might not go down but Medicare would go up... It's SO complicated.
It would be a question of degree rather than completely giving up, wouldn't it? Also facing up to the fact that it's more feasible to adjust the ACA than to come up with something very different. Some of the things they've talked about would be deeply unpopular with a majority of voters.
What Romney did - and what Obama did - is actually basically what the republican plan WAS for 20+ years. It came out of The Heritage Foundation in the 70s and was first supported by Nixon. Think about it - the government pays money and forces people to buy private insurance. Sounds pretty republican. There are difference, but one basic reason the republicans don’t have an alternative is because ACA was their plan…. Your explanations are excellent!
For those who are very interested in this topic, the Bulwark just published a piece that alludes to the constraints that Josh has explained so clearly, and delves into some other aspects of the politics.
https://www.thebulwark.com/p/trump-discovers-yet-again-that-health-care-policy-is-hard
Josh, I quoted you in a comment on the Bulwark article and listed your key points (the trilemma). I couldn't figure out how to link it, sorry. I did give the article title and name of your Substack, so people ought to be able to search it out if they're on Substack.