Will the GOP "solve" access to health care? No, unless you can redefine "access"!

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.

Private Profit and the Public's Health: Which is More Important?

Health care is pretty complicated, and insurance coverage is even harder to understand.This is the message that comes through clearly from the interviews being done by Dr. Paul Gordon and recorded on his blog, https://bikelisteningtour.wordpress.com. Dr. Gordon is taking a unique sabbatical, riding his bicycle across the country from Washington (DC) to Washington (state), interviewing regular people, mostly in cafés and such, about their take on Obamacare. 

The economic status of these people varies from poor to pretty well-off (but none really wealthy), from well insured to uninsured. Their political perspectives range from “everyone should be covered” to “benefits just make people lazy”. Three recent quotes: ‘People use Medicaid as a crutch’, ‘You can’t penalize someone for not having health insurance when it’s so expensive and the economy is doing so poorly’, ‘Here’s my take on it – everyone should have insurance’. What they share with each other, and with most of us, is a general lack of understanding of how Obamacare works (or doesn’t) and why. The flaws in Obamacare are the result of the political tradeoffs that allowed insurance companies to continue to have control and make huge profits, but this is often not clear to most people.

Here is something that is easy to understand, however: when you call “911” as you have been trained to do in an emergency, and they don’t come. Or they don’t come for a long time. Or they come with inadequate supplies. Who do you get angry with when you, or your loved one, dies? The government? They are surely in part at fault, even though they probably contracted the service out, to save money, probably because voters want to pay less tax. But there is another reason, explained in an excellent special article in the New York Times, “When you dial 911 and Wall St. answers” (June 26, 2016). The piece, by Danielle Ivory, Ben Protess, and Kitty Bennett, details how many city services, including ambulance services, are provided by companies that are owned by “private equity firms”. These are companies whose investment capital comes from wealthy individuals and particularly from pension funds, unlike banks whose money comes from depositors. They are even less regulated than banks, and thus more able to pursue their core mission, making profit:

Unlike other for-profit companies, which often have years of experience making a product or offering a service, private equity is primarily skilled in making money. And in many of these businesses, The Times found, private equity firms applied a sophisticated moneymaking playbook: a mix of cost cuts, price increases, lobbying and litigation.

Whoa. This is starting to get complicated again. Banks vs. “private equity” vs. just plain old for-profit businesses? They are really just different forms of for-profit, and provide a stepwise progression, from public services operated by government for the benefit of the people, to private companies that are contracted by government to do a service but might care about doing it well, to having those companies owned by banks who really just want to make a profit, to having them owned by private equity companies who care about nothing but making a profit. The photo accompanying the Times article is of Lynn Tilton, owner of Patriarch Partners (an ironic name, given that she is a woman), which owned the emergency services company TransCare that served many East Coast communities. TransCare went bankrupt, leaving those communities without emergency medical services. Ms. Tilton’s picture is accompanied by the quote from her reality television stint “It’s only men I strip and flip.” As a poster child, she could become the Martin Shkreli of ripping off necessary public services the way he was of ripping off consumers of life-saving drugs.

“The business of America,” Calvin Coolidge is often paraphrased as saying, “is business.” This perspective, that it is not about doing things that are best for the American people, is based in a belief that capitalism – “business” – will, through the magic of the market, eventually meet those needs. OK, maybe not those of people at the margins, people too poor to buy, so maybe we need a safety net. But most people. A similar statement appeared today in the print edition of the Kansas City Star from KC Mayor Sly James, discussing the controversy over replacing the terminals at Kansas City International Airport with one big, new terminal. Surveys consistently show that the large majority of Kansas Citians (84% in this article, “Regarding KCI’s future, city ponders a new flight path”) like the current arrangement, with short security lines and easy access in and out from one story terminals, but the airlines and big businesses do not. In the large-type quote accompanying his picture in the print edition (but, along with the photo, left out of the online edition), Mayor James said “The people of this city need to be convinced of what I believe is a basic reality, that this airport is about a lot more than ‘how fast can you get out of your car and get to your gate?’” Right. Business interests first. Take that, 84% of Kansas Citians!

Because they most obviously involve life and death, emergency medical services and firefighting (yes, firefighting too has been contracted out to companies owned by private equity firms!) get the greatest play in the Times article, but many other services (like water!) are in the same situation: controlled by companies whose goal is to make a profit rather than to provide effective service for people. This is what happens when municipalities are starved of funds because people vote to cut taxes.

Whether it is health insurance or emergency medical services or municipal water, the system becomes very complicated and hard to understand when it is trying to meet conflicting agendas. When the need for people to receive critical, health-producing service (fire and police protection, clean water, garbage collection, ambulances) is compromised by provisions built into contracts (or the law) for companies (insurance companies, banks, private equity firms) to make profit. I guess it is fine if these services can be effectively and reliably provided by for-profit companies, but when their pursuit of profit through “a mix of cost cuts, price increases, lobbying and litigation” conflict with actually providing services, there is a big problem. In the case of emergency medical services, the problem was that “…many newly insured Americans turned out to be on Medicaid, according to the Kaiser Family Foundation. Medicaid restricts some of the most aggressive billing tactics.”

A variety of other difficult to understand strategies are also employed at the macro level to place the interests of wealthy corporations above those of the people. These include the unlimited political contributions permitted by the Supreme Court’s Citizen’s United decision, incredible gerrymandering of congressional districts so that we have states where the majority of voters vote for Democrats but most districts are solidly Republican (see the New York Times Book Review “Where votes go to die”, June 26, 2016), and the provisions of the Trans-Pacific Partnership (TPP) that prevent national governments from regulating multi-national corporations.

We could solve this if there was a single, over-arching principle, always codified into law, that the interests of the people as a whole always trumps the profit potential of corporations. I vote for that.