Members of Congress are home in their districts for a week-long break, and many lawmakers are expected to get an earful from voters upset over many issues at the start of the Trump Administration, especially this: What the heck’s going on with health care?
Republicans have insisted for years now—counter-factually, as the evidence has amply demonstrated—that they had a cheaper, better, more inclusive alternative to the Affordable Care Act, aka Obamacare. The promised to repeal the ACA on the day they gained control of Congress and the White House. That hasn’t happened. Nor has the GOP proffered its vaunted replacement. Instead, the party had talked in recent days about an ACA repair.
But under fire from their most conservative party members, Republican leaders have thrown up what they call an outline of Trumpcare. The GOP has moved from lots of R’s—repeal, replace, and repair—to some C’s and D’s: Costly, callous, divisive, and cruel. Those are some ways their retread plan elements (dubbed “déjà vu all over again” in one report) could be described. The outline still faces major challenges, not the least of which is whether a chaotic White House and a lumpen Congress can conduct the nation’s business and enact public policy.
Still, there are disturbing strains emerging in Trumpcare.
First off, those who want to dive into its available and still developing details can read: The GOP policy memo (click here); the New York Times news story (click here); the Washington Post story (click here); the Wall Street Journal story (click here); and an analysis by Margot Sanger-Katz, a columnist for the “Upshot,” a policy- and research-driven New York Times news feature (click here).
Seeing exactly where the GOP is heading on health care may prompt many to get motivated to exercise their democratic rights and to reach out to their elected officials. GOP lawmakers, already cowed by large crowds, are canceling town halls or holding them electronically. Activists are providing on-line resources to learn where sessions are scheduled (click here) and others are listing other ways activists may let elected officials know what’s on their minds (click here).
So just what are GOP officials, including the Trump Administration and House Speaker Paul Ryan (shown above), up to on health care:
IRS will stop checking on health coverage
- The Internal Revenue Service, under a presidentially ordered policy change, no longer will check if Americans carried health insurance as required under the ACA. That move could destabilize insurance markets even before the GOP has an ACA replacement, and some are calling this a “stealth attack” on Obamacare. The ACA sought to get as many Americans as possible, those healthy and sick, and young and old, insured to spread and balance the costs and risks of health care. But the GOP has denounced the individual mandate as coercive and an unwarranted intrusion by government into Americans’ lives. The IRS was a mainstay of mandate enforcement, checking whether tax filers carried ACA-required health insurance and imposing penalties, including fines and withheld returns owed.
Partisans riven over what to do about Medicaid
- Ryan and other GOP leaders have not corralled party members yet on the major issue of what happens with Medicaid, a program that helps the poor, old, and chronically ill with coverage and care. It was significantly expanded under Obamacare, with 32 states agreeing to cover 12 million more people with greater federal assistance to do so. In the states where this occurred, Republicans could experience major backlash if they cut off or cut back Medicaid, as conservative stalwarts in the party insist must occur. I’ve written about what a nightmare it will be if the GOP converts Medicaid from a government-guaranteed program to one funded with block grants with financial support that not only would vary year to year but also would likely plummet over time. Indeed, the GOP, though it is talking about creating a hybrid that would let states choose if they want to keep what they have or adopt block grants, has a steel hand in this velvet glove: Overall Medicaid funding will plunge. More key: States that expanded their program on promise of federal support will see that money fall off a cliff, going from 90 percent underwriting to half. That could mean budget hits of billions of dollars in big states like New York, Michigan, and California. The cruelty of the “new” GOP Medicaid plans not only is unchanged from previous party proposals but it flies in the face of what President Trump has said would be “beautiful” health insurance coverage and care for all Americans. As I’ve said before, his voters already have suffered from GOP intransigence in the 19 states that declined to expand Medicaid. Even more of his voters will be savaged under the emerging ACA repeal-replacement with its attack on Medicaid.
Health plans that divide Americans
- Although Ryan and colleagues continue to insist that they’re benefiting Americans with their Obamacare assault, that is not evidenced in their outlined plans. As the New York Times’ Upshot column makes clear, GOP proposals would divide Americans, favoring the rich over the poor and the young over the old. This will occur in tax credits or deductions (Republicans can’t decide which) they see Uncle Sam providing for health insurance. They would reverse how Obamacare works, eliminating income preferences for aiding the poor and less affluent, as well as trying to ensure markets’ stability by bringing in more of the young and healthy. Instead, the GOP would give bigger tax incentives for insurance to older and richer Americans. It is true that seniors may have greater health needs. But by putting their entire focus on age and not income, the GOP will ensure that older billionaires get the same health insurance support as do elderly widows scraping by Social Security. Further, the party persists in plowing ahead with health savings accounts (HSAs) as a key component. These accounts have their place, but, again, only the more affluent will have money to bank in tax-advantaged HSAs. Too many Americans struggle to meet the monthly nut. Experience already shows how slammed many are trying to afford the out of pocket costs of high-deductible, employer-provided health insurance. Vox, an online news site, has looked back at an ACA replacement plan floated by Tom Price, then a Georgia congressman and now Health and Human Services secretary, to get a sense of the health insurance aid that might be in Trumpcar Vox reports that for an American older than 51, the tax credit would be $3,000—a sum 61-year-old Bill Gates (net worth $83 billion) would qualify for, as well as would a Northeast Washington, D.C., retiree living on Social Security. But, the site notes, health insurance for a 55-year-old reporter living in the district, under Obamacare exchanges, costs about $8,000 annually. How does that gap get bridged? It may be that any Trumpcare just would offer many fewer benefits.
Absent financial details
- If there’s an air horn sounding, consider it the necessary alarm that the GOP isn’t outlining how it will pay for Trumpcare. A semi could be driven through sketchy proposals partisans are driving now. Will GOP plans, despite partisans’ insistence otherwise, leave so many Americans with so much less health coverage that the nation returns to days when hospitals are overrun with sick patients who cannot pay and cannot be turned away—and how will billions of dollars in uncompensated care be paid for? Yes, the GOP may free up big sums by slashing Medicaid. But Obamacare, as it had to, penciled out with its own taxes and fees that funded its programs, and the GOP hasn’t provided its alternatives, other than to promise that they will be forthcoming. Sometime.
Big interests vs. ordinary Americans
In my practice, I’ve had plenty of dealings—too many of them excruciating and frustrating—on behalf of clients battling insurers. As I’ve said before, the GOP’s Pollyanna-ish views about free markets, beneficial competition, and the munificence of corporate interests like big insurers are, well, naïve, callous, and counterfactual. Partisans are showing their willingness to load too many Americans on their own health care rafts and shove them out to sea with a few crackers and a tiny canteen. Have Americans forgotten how fraught health insurance was, especially on individual markets, pre-Obamacare? Do most of us have the time and knowledge, armed with small sums under Trumpcare, to research and negotiate health insurance, in sunny times (when it may be tempting to take skimpy plans that may proliferate anew) or when we or our loved ones are sick and desperate? Inherent in GOP proposals, to me, is a misguided faith not in individual Americans and their freedoms but a belief that big insurers will behave in our best interests.
Ryan has quoted insurers in claiming, falsely, that Obamacare is failing. But look at several he cited as insisting they were withdrawing from ACA exchanges due to lack of profitability: The record shows they are as much licking their wounds from negative business decisions of their own—failed merger attempts—as from Obamacare. Michael Hiltzik, a Los Angeles Times business columnist, has analyzed the Aetna-Humana flop. He says Aetna’s CEO decided to slash the company’s Obamacare rolls from a little less than 1 million customers to a quarter million or so, blaming them and the exchanges for $450 million in 2016 losses. But at the same, Aetna’s CEO found it acceptable, in the name of consolidation and potential profit boosting, to fritter away $1.8 billion to try to merge with Humana in a $37-billion deal wobbly from the start. No sooner did those two insurers squabble than did Cigna announce that it was suing Anthem, its failed partner in a planned $54 billion merger deal, over a $1.85 billion termination fee and what it claims were $13 billion in damages.
When Big Insurers, Big Medicine, Big Pharma, big hospitals, and big-time doctors and other caregivers decide to roll over all of us, is there any chance that our democratically elected government will play a big role in ensuring that we get health care that is safe, affordable, accessible, and outstanding? Most of could care less if it is called Obamacare, the ACA, or Trumpcare. The stakes are huge and we need to ensure anything that follows what we have is an improvement, not a setback.