An editorial in the New
York Times on February 20, 2017 (“Ryancare:
You can pay more for less!”) does a very good job of concisely
demonstrating what the new Republican plan is likely to do to access to health
care, the cost of health insurance, and what it covers. The key to House
Speaker Paul Ryan’s plan for replacement of Obamacare involves “…flat tax
credits unrelated to income, that could be applied to the purchase of
insurance” (Paul Krugman, “Death
and tax cuts”, NY Times February
24, 2016). As Krugman makes clear, the credits would be insufficient for low
and middle income families to buy insurance, but would be a small benefit to high
income households. The obvious result would be the loss of health insurance for
millions of Americans who gained it through either the ACA exchanges and
accompanying subsidies or through Medicaid expansion.
Giving tax credits or deductions is a long-standing
Republican strategy that pretends to be equitable but in reality always
benefits the financially better off. Ivanka Trump (the President’s daughter who
is not, it should be observed, elected or even appointed to anything) has her
pet project, tax deductions for childcare. Again, this sounds good,
especially to the more well-off, two-income couples who would benefit (but
don’t get your hopes up; the $500 billion tab makes it unlikely to pass even
with the First Daughter’s support), but would be of less benefit to the poor.
The one thing that is certain about Republican and Trump policy is that it will
benefit the better-off; the problem with such deductions, from their point of
view, is that it is costly and doesn’t benefit a narrow enough slice of the
highest income individuals and corporations (sorry, Ivanka).
As summarized in MedPage’s
Washington Watch Policy Papers on ACA Repeal: Many Question, Few Answers, no
one, outside the Republicans pushing it, has any belief that the Ryan plan will
provide coverage for most of the people who gained coverage from the components
of the ACA, not to mention those who remained uninsured even with ACA in place,
mostly poor people in states that did not expand Medicaid and undocumented
people, as well as those who risked the penalties for violating the individual
mandate rather than buy health insurance that they felt they could not afford.
The first two groups are completely left out of any “replacement” plan (and of
course undocumented people were never part of Obamacare). None of these plans
will in any way benefit the middle and lower income people who voted for Trump
in part because they wanted to get rid of Obamacare, which was costing them too
much, and get the terrific, affordable health care coverage that the President
promised them in the campaign. It is not going to happen, and people are
beginning to understand that; CNBC reports that Obamacare
is getting more popular in the first month of Trump’s presidency.
All that has been revealed so far about
the content of a Republican “plan” indicates that it will cover fewer people
than the ACA currently does. Some of this has to do with the mechanism of
funding, with “tax credits” replacing direct subsidies for lower-income people.
There is even a debate among Republican lawmakers about whether those tax
credits should be “refundable” or not; if they are, then people will get the
amount designated for the tax credit even if that amount is greater than the
amount they would have owed in Federal income tax. Thus, it would be a subsidy,
and thus many “conservative” (their word) Republicans oppose it. For a very
large percentage of those who would be buying insurance and need help, the
amount would likely be greater than the amount of Federal tax they owe. Of
course, this depends upon how much the tax credit is determined to be; one
thing, however, is that there is essentially no chance that it will be enough
to actually purchase insurance.
Which brings up another big part of
the way Republicans talk about health coverage. They use the term “access”
rather than coverage, and have defined it in such a way that it is different
from coverage; people, they say, will have the option of buying health
coverage, not be forced to, the way that the ACA’s individual mandate did. This
requires a conscious effort to ignore the crucial “ability to pay for it” as
part of access, and makes the idea of “option” insincere. Something is not an
option if you cannot afford it. Sen. Bernie Sanders said, in a good takedown of
this use of “access”, that he had access to
purchase a $10 million house; he just didn’t have the money to do it!
Insurance companies are a big part of
the problem for ACA. The absence of a “public option”, not to mention a
single-payer plan, meant that the law had to build in a way for insurance
companies to be able to make money. To be able to profit, they have to either
be able to charge a lot for coverage (or deny it altogether) for sick people,
which was the pre-ACA status quo, or have a large pool of healthy low-cost
people buying insurance. Thus, especially given ACA’s elimination of their
ability to refuse insurance to people with pre-existing conditions, the
individual mandate, requiring everyone to buy insurance, was needed. Despite
the mandate, though, not enough healthy people bought insurance, and there was
no rate cap, so it quickly has become unaffordable for many. Of course, we
could have done what other developed countries do – have either a single-payer
system where we have everyone automatically in the risk pool and everyone is
actually covered, or have a highly regulated system, where benefit packages and
rates are set by the government and insurance companies are non-profit, so compete
on customer service. We actually have examples of both in the US. Medicare is a
single payer plan (and while Medicare Part A, hospital, is paid for by the
Medicare trust fund, Part B, doctor and outpatient bills, require individuals
to pay, with high-income people paying a
supplement), as is the military health care system and the VA. Medicare
supplement (Medigap) plans are regulated with regard to benefits; there are a
number of plans lettered Type A to Type N (except there is no E, H, or I) with
different benefit packages. The degree of comprehensiveness does not follow the
alphabet (F is the best, K probably the worst) but at least they are
standardized so all Type A, C, F, or K plans offer the same benefits regardless
of which company you buy from, and so you can shop based on price.
I do not think that we are going to
have such a simple situation as a highly-regulated marketplace, and certainly
not single payer. We are likely going to back as far away from comprehensive
coverage and affordable health care as the Republican Congress and President
can get away with, which means as far as the American people will allow. Of
course, the American people (other than the small number of, but incredibly
powerful, wealthy ideological conservatives) do not want to lose their health
coverage; they just want to pay less. Or not pay until they are sick. For them,
and maybe for their families. For others, maybe not so much; some studies have
found that as many as 2/3 of Americans
support Medicare for All, while for Dr. Paul Gordon on his “Bike Listening Tour” across
the US in 2016, one of his most upsetting findings (at least among the mostly
white, rural, northern people he interviewed) was people’s lack of concern for
others. Or at least “the other”, folks not like them.
It’s a real shame. We could have
comprehensive quality care for everyone, at a more reasonable cost. Too bad the
ideologues and the greedy are in control.
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