It's a difficult problem, but they are making it harder. Actually Obama and the dems made the issue unnecessarily difficult by virtue of wrapping it all up in one enormous bill. Unraveling that ball of thread will be tough because you have to have some sort of replacement ready.
It does seem to me there are three separate issues, and two closely related ones. One is people who can afford private insurance and are willing to buy it. They should be able to access a free market, where carriers can offer plans nationwide with various coverage options, ie major medical only, high or low deductibles, etc. These people are Trump's core constituency and if he screws them, he can kiss reelection goodbye.
The second group are people who cannot afford coverage. The problem with obamacare is that they ended up with better coverage than the first group. Many are illegals who are not even supposed to be in the program. There are a number of options here. Typically, Ryan chose the worst one, giving them in effect government vouchers to buy insurance through tax credits. It seems better to me to put them all in Medicaid or some other government plan. It's welfare and that's what we should call it. these people tend to be big consumers of health care, so keeping them out of private plans should lead to cost savings.
The third group are people who could have purchased insurance but didn't. Perhaps they are young people who develop a serious condition with no health insurance. They have to go in the second group but with a big penalty charged. They will get worse care than the first group and pay through the nose for it. Risky decisions have consequences.
Two related issues. One, employer-provided insurance is a big problem that needs to be ended. It makes our companies uncompetitive internationally, it keeps people in jobs they hate and it is unfair to the self-employed. Unfortunately it is popular. It is a big tax break for employees. Do away with the tax break and the reason for it essentially goes away. Probably the easiest way to do this is to give people a tax writeoff for insurance, employees and self-employed alike. Not ideal tax policy but doable.
The other issue is drug prices. Americans finance pharma R and D for the entire world because other countries use patent protection as leverage to set prices. That's why you can buy the exact same Rx in Canada for a lot less. Similarly, we prevent medicare from negotiating low prices. Republicans will just have to bite the bullet here and decide if they want to be reelected or get pharma campaign money, because it doesn't look like both are possible. You can expect howling from the free market "conservatives" here, but the drug companies have done Trump a favor by price gouging, so the public is with him. The conservative purity test was violated anyway when the government started paying for this stuff.
