President Trump has made good on his promise to try to blow up the Affordable Care Act, aka Obamacare. His latest, twin executive actions seek to gut the national health insurance program that Republicans have reviled but could not unwind with seven years of congressional action.
If the American health care system was rocky before, and if it breaks, Trump and the GOP now own it, analysts insist. That’s because the president, effectively, has officially given the nation Trumpcare, though it, too, has an uncertain path ahead.
Although partisans had vowed that their ACA repeal and replacement would result in better, more affordable, and more accessible health coverage for Americans, Trumpcare goes nowhere close to any of those goals, experts say.
Instead, it offers for now retread and often failed policy prescriptions that may mean cheaper, shorter, and significantly skimpier policies that protect consumers much less. Trumpcare whacks at the poor and middle-class, dividing the healthy and sick and the young and old. The president, for now, hasn’t taken aim at Medicaid, the health program for the poor, old, chronically ill, and children. That may occur on a state by state basis.
And Congress and federal bureaucrats—including in, of all places, the U.S. Labor Department—may yet have a major say still as to how Draconian Trumpcare becomes. It seems certain, too, that the courts will be involved, bigly, meaning health insurance markets that rely on certainty to help constrain costs will be consumed with yet more and long uncertainty.
Ordinary Americans will be hurt by all this, too, not the least as the president also has sought to eviscerate other aspects of the ACA, most notably the crucial programs that try to increase its enrollments, especially to balance out the risk-pools with younger, healthier consumers.
Trump took what may be his biggest swipe at Obamacare by eliminating “cost-sharing reduction payments,” or CSRs. These sums—$9 billion next year and more than $100 billion over the next decade—were to go to insurers to help defray out-of-pocket costs of covering poor Americans. Republicans have argued that President Obama illegally created the subsidies with regulations created by federal agencies after Democrats passed the ACA.
The subsidies will keep going to the poor, but insurers will eat those costs—and pass them on to others. Or companies may decide to quit ACA markets, leaving consumers with no coverage option. In some states, regulators have forced insurers to anticipate a possible elimination of CSRs into rate hikes already fixed for 2018, and consumers in these mostly blue states will face premium increases but greater coverage certainties.
The Congressional Budget Office, however, has said eliminating the CSRs would be destabilizing to insurance markets, estimating that 1 million more people would become uninsured in 2018, prices for insurance would rise by 20 percent to 25 percent, and insurers would drop out of some parts of the country.
At the same time, because the ACA provides other subsidies to some consumers when their premiums rise—as they will when the CSRs vanish—the nonpartisan, independent analysts of the CBO estimate that federal deficits will increase by $6 billion in 2018, $21 billion in 2020, and $26 billion in 2026.
Trumpcare, therefore, pleases GOP partisans but starts by making health insurance not only costlier for many Americans—mostly in the middle-class and many in the “gig economy,” meaning they don’t get employer coverage—but also for all taxpayers by increasing the deficit.
The executive order
Partisans, however, point to a separate Trump executive order to claim that many consumers will get cheaper coverage through short-term and “association” plans (policies for small businesses or groups of casually related people who band together in groups), as well as Administration efforts to foster the sale of health insurance across state lines.
The notions, which the president’s executive order “called on” various federal departments to put in place—absent concrete specifics from Trump, by the way—are familiar. They have been tried without success. It’s wearisome to cite how reality debunks the GOP myth of great benefit from sales of health policies across state lines. The short-term and association plans too often over-promised and under-delivered, sticking consumers with policies that may have been cheap but also were meaningless.
Trumpcare might favor these options because, among other things, they may or may not provide: essential benefits (including emergency services, drug coverage, or provisions for women’s reproductive health), prohibitions on caps on insurers’ annual and lifetime liability; and, of course, protections so consumers could not be denied coverage based on preexisting conditions or charged significantly more because of their age or health. Slashing at these provisions, it should be noted, also may imperil coverage offered to most Americans at their jobs.
Americans may be more familiar with the kinds of companies that have raced in to offer cheap, skimpy short-term or association plans because they sometimes see their analogues in auto policies. Sure, high-risk drivers sometimes can meet local laws and get liability policies from sketchy operators. But woe to them—and anyone else—if they’re in a wreck and then need their insurance to provide.Cars and wrecks can be painful and costly, as I know from my extensive practice experience with them. But consider how much direr the circumstances might be if consumers buy skimpy coverage, then learn they have cancer, heart disease, or a costly chronic condition.
Coverage can be key
In my practice, I see the significant harms that patients suffer while seeking medical services, and their huge struggles to afford medical care, especially as they grapple with the existing complexities and uncertainties of health insurance. To be clear, Trump and the GOP have forced Americans into an endless brawl over insurance coverage while also not engaging in equally critical discussions of the cost, quality, affordability, safety, and access to medical services. But, alas, insurance is a key that unlocks better health and well-being for us all.
President Trump made big, brash promises about how he would improve the U.S. health system, especially insurance coverages. Since taking office, however, he not only has failed to follow through but he also has shown incapacity or indifference to not only the reality and execution of public policy but also the basic human empathy and compassion needed to lead the nation and to govern well. The annual ACA open enrollment period begins Nov. 1, and Americans need to get the word out—especially because the Administration will not—that there are vital coverages available still.
Obamacare is imperfect and it needs fixing, not scrapping. If the president offers real, demonstrable improvements instead of the ACA, the nation would be grateful to him and embrace his plans. But that ground may be far too high for Trump and the GOP after a year’s campaigning against the ACA, in which they have demonstrated that their real zeal isn’t to help the sick, needy, poor, aged, children, middle class or the preponderance of Americans. No, the partisans have shown they lust only for tax cuts for the richest few. We need to keep pushing back in a united fashion against that unacceptable path. Health care must be a right, not a privilege.