Imagine the dynamic economy we might have if Americans weren’t tied to their jobs for employer-provided health care?

Medicare for All is popular on the left but it’s not the only option. We could strengthen the Affordable Care Act and allow people 55 and older to buy into Medicare. Either way, the result could be millions of entrepreneurs unleashed at a time when the rate of startups has been slowing for years.

Instead, the country is going in the opposite direction. The Trump administration announced this week that it will support a court decision invalidating all of the ACA. With Brett Kavanaugh now on the bench, Obamacare might finally meet its end when the case inevitably reaches the Supreme Court.

If that happens, at least 21 million Americans could lose their health insurance. Some 133 million would lose their protection against being denied insurance for a pre-existing condition.

Obamacare was never perfect. It made use of the existing private insurance system rather than replacing it. But it was politically doable.

Although it faced years of Republican attacks and sabotage, it brought the number of uninsured to a historic low. About 800,000 Washingtonians receive care through ACA. It’s now deeply embedded in the national health-care system.

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According to a report from the Henry J. Kaiser Family Foundation, “If the Affordable Care Act were overturned, it would affect nearly all Americans in some way.” For example, ACA provides protections to the 156 million people receiving coverage from their employers.

In directing the Justice Department to request court repeal of ACA, Trump told reporters that “The Republican Party will soon be known as the party of health care. You watch.”

Unfortunately, the GOP has no plans, despite years of sloganeering about “repeal and replace” ACA and the more the 50 times the Republican-controlled House voted to eliminate Obamacare.

Seeing the political poison from going after ACA, House Republican leader Kevin McCarthy of California tried to dissuade the president, to no avail.

As it turns out, Sen. Marco Rubio, R-Fla., told Bloomberg that Trump “didn’t offer a plan.” A Washington Post-ABC poll found that only 33 percent of respondents said Trump has done a good job improving the health-care system.

The parties are divided by a profound philosophical and moral divide. Most Democrats argue that health care is a basic human right. Most Republicans today don’t believe that — the party has come a long way since President Richard Nixon proposed a major expansion of health-care access.

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Republicans succeeded in hobbling Obamacare, especially in states that refused Medicaid expansion, by scaring voters. “Keep your government hands off my Medicare,” was the viral protest ahead of Democratic losses in 2012 after passing ACA.

Even so, according to the Pew Research Center, 60 percent of Americans “say it is the federal government’s responsibility to make sure all Americans have health-care coverage.”

The U.S. system is by far the most expensive in the world, about twice as high in other advanced nations, almost all of which offer some form of universal care. But outcomes such as life expectancy and infant mortality are worse here.

“All the evidence is that we haven’t paid enough attention to prices,” Dr. Ashish Jha of Harvard’s T.H. Chan School of Public Health told Boston public-radio station WBUR. “And prices are where we are truly exceptional. We’re just higher for everything — drug prices, physician prices, nursing prices, hospital prices, MRI prices.”

For example, an MRI session costs an average $1,119 in America compared with $503 in Switzerland and $215 in Australia. The hepatitis C drug Harvoni costs $10,000 more here than in other nations.

It’s an enormous burden on the economy, consuming nearly 13 percent of gross domestic product in 1991 and nearly 18 percent, or $3.3 trillion, in 2016. Australia spent 9.6 percent of GDP in 2016.

These high prices are the result of a highly inefficient private system, especially the greed of big entities such as pharmaceutical, medical device, hospital and insurance companies. The federal government doesn’t force drugmakers to bid for the lowest prices in Medicare Part D.

The power of big health care means enormous political influence to block any changes to the status quo.

In the 2018 election cycle, the health sector contributed nearly $256 million to candidates, 55 percent of it to Democrats. Among industries this ranked fifth, according to the Center for Responsive Politics. This came at a time when a CNN exit poll said 41 percent of respondents considered health care “the most important issue facing the country” (75 percent were Democrats).

The paradox is that strengthening ACA or going further is a potentially winning issue for Democrats in 2020, but the lobbying strength of the health-care industry will try to prevent reform.

More alarmingly, the Supreme Court might find ACA unconstitutional before the next election. That might raise legal roadblocks to Medicare for All or other efforts to broaden health-care access even if Democrats rode a wave of discontent — and sloughed off industry lobbying — to claim the House, Senate (unlikely) and White House.

But populism cuts both ways, especially with most Americans supporting broader access to health care for themselves and their fellow citizens.

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“The worse the better,” Lenin supposedly said. But you don’t have to be a Bolshevik to wonder if the shock to the nation’s economy, health and moral concerns from the loss of ACA might finally force change. A change that even a reactionary Supreme Court can’t stop, especially with Chief Justice John Roberts so concerned with the court’s legitimacy.

Still, it’s a high price to pay in lives and suffering.

When I was at lunch today, two construction workers at the next table were discussing the danger to Obamacare.

One said, “The consequences would be incalculable.”

Economics columnist Jon Talton

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