As Republicans struggle, Obamacare's architects outline how it could be fixed

Susan Page | USA TODAY

Show Caption Hide Caption Obamacare architect on how to fix it Dr. Ezekiel Emanuel doesn't think the AHCA will pass through Congress and shares his ideas about how Obamacare could be improved, rather than repealed. He speaks with Susan Page, USA TODAY Washington bureau chief, on Capital Download.

ASPEN, Colo. — As Senate Republicans struggle to find the votes to repeal the Affordable Care Act, the architects of Obamacare have an idea to try if they fail.

Just fix it.

Senate Majority Leader Mitch McConnell on Tuesday delayed the vote planned for this week on the Republican health care plan as complaints from competing wings of his party made it uncertain whether he commanded the support even to begin debate, much less pass the bill.

But those who oppose repealing the Affordable Care Act caution that the GOP's failure to act would create complications of its own, both for those who gained insurance coverage through the Obama initiative and just about everybody else.

"There's nothing insurance companies hate more than uncertainty, and one of the things they do to respond to uncertainty is to increase their premiums," Ezekiel Emanuel, a bioethicist and University of Pennsylvania professor, said in a Capital Download interview Tuesday at the Aspen Ideas Festival. Premiums for those who buy insurance through the Obamacare exchanges, already rising, would increase more, pricing some Americans out of the market. Those who get insurance through their employers also would feel the effect as hospitals spread the costs of treating the uninsured.

"The notion that anyone in America is going to be better off if the Affordable Care Act crashes and burns is ludicrous," he told USA TODAY's video newsmaker series. "All of us will pay for it in the end. There is no free lunch here."

Emanuel played a key role in the Obama White House in devising the Affordable Care Act. But he also met with Donald Trump three times since the November election to discuss health care policy, most recently at the White House in March. (It's all in the family: Emanuel's brother Rahm, now Chicago mayor, was Obama's chief of staff. His brother Ari is a Hollywood agent who has ties to Trump and encouraged the president-elect to talk with him.) Zeke Emanuel's latest book, Prescription for the Future: The Twelve Transformational Practices of Highly Effective Medical Organizations, was published this month.

His sessions with Trump left him perplexed, Emanuel says. "He wants to get everyone covered; he wants costs to be under control so people aren't being denied care because of the deductibles or the co-pays; he wants drug costs to come down," he says. "This (Senate) bill does none of that, so it seems like a total discord between what his guts tell him to do and what the bill does."

Republicans argue that Obamacare is in a "death spiral" because of its own flaws; Democrats counter that actions taken by the Trump administration and congressional Republicans have sabotaged it.

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In any case, Emanuel and Kathleen Sebelius, secretary of Health and Human Services as the law was being devised, debated and implemented, say there could be bipartisan agreement on steps that would stabilize the current system, help control costs and protect care.

Among their suggestions:

Reassure skittish insurance companies. "Very, very quickly, the Republicans need to say to insurance companies, as we work on a new theory of replacement, we will keep this law in place," Sebelius says, including a commitment to continue the subsidies that help lower-income Americans afford premiums. Announcing that the law's mandate to have health insurance is going to be enforced would help as well, Emanuel says.

"Very, very quickly, the Republicans need to say to insurance companies, as we work on a new theory of replacement, we will keep this law in place," Sebelius says, including a commitment to continue the subsidies that help lower-income Americans afford premiums. Announcing that the law's mandate to have health insurance is going to be enforced would help as well, Emanuel says. Change the way doctors and hospitals are paid. If they receive federal payments through Medicare, Medicaid or the military's Tricare system, Emanuel proposes a mandate that they spend a rising percentage of those funds on models that focus on wellness and prevention rather than a fee for each procedure performed.

If they receive federal payments through Medicare, Medicaid or the military's Tricare system, Emanuel proposes a mandate that they spend a rising percentage of those funds on models that focus on wellness and prevention rather than a fee for each procedure performed. Negotiate lower drug prices for Medicare and Medicaid . "There wasn't enough Democratic support to do something about drug costs" when the Affordable Care Act was being drafted, Sebelius says. "That sentiment has changed dramatically over the last seven years."

. "There wasn't enough Democratic support to do something about drug costs" when the Affordable Care Act was being drafted, Sebelius says. "That sentiment has changed dramatically over the last seven years." Provide incentives for insurance companies to participate in the exchanges. A few states now give preferences for their Medicaid programs to insurance companies that also participate in the Obamacare exchanges.

"Say 'we're going to work on it until we find a better bill,' " Sebelius says. "But what's going on right now, if they fail to not only have legislation passed but an infrastructure in place at the end of this year, they will have a total mess on their hands. They will have the worst of all worlds."

That said, there's limited optimism about the prospect for any bipartisan cooperation in the foreseeable future.

"We agree on 70% of policy," Emanuel says. But Republicans decided not to reach out to Democrats during the debate, arguing their opposition was set. And Democrats now see no percentage in rescuing Republicans from their political straits, at least not before next year's midterm elections.

"When you piss off the other side and basically spit in their eye — we're not going to talk to you; we're not going to involve you; we're going to keep all the marbles; we're not holding public hearings; we're not debating this — what's their motivation for working with you?" he asks. "It's zero."

And who gets the political blame if the nation's health care system becomes a fiasco?

Sebelius, who saw the political damage that Obamacare's stumbles created for Democrats in 2010, predicts it would be the GOP this time: "I believe that whoever is in charge when the collapse happens owns the collapse."