What the administration says it’s doing and what it’s actually doing on health care are worlds apart.
As Democrats debate the best way to achieve universal coverage and lower health care costs, the Trump administration has a different approach to the challenges of our current system. It’s working overtime to make the system more fragile for the sick and the poor, even as it misrepresents to Congress and the American public what it’s up to.
Speaking to reporters in late October, President Trump said that “we have a great Republican plan” to replace the Affordable Care Act. “Much less expensive. Deductibles will be much lower.” His statements came on the heels of a congressional hearing in which one of his top health officials, Seema Verma, said that the administration would do “everything we can” for Americans with pre-existing conditions. Under oath, she swore that the administration was aiming to help people find a pathway out of poverty.
None of this is true.
Far from supporting protections for people with pre-existing conditions, the Trump administration has thrown its weight behind a lawsuit seeking to topple the Affordable Care Act. In court filings, if not in its public statements, the administration is clear about what it wants done to the law: “The proper course is to strike it down in its entirety.”
If the lawsuit succeeds, protections for people with pre-existing conditions would be wiped from the books. Overnight, we’d be back in a world where private insurers could discriminate against the sick.
Good luck getting Congress to pass one. Though Republicans have no shortage of white papers endorsing controversial reform plans — the Republican Study Committee, a group of legislators, recently released another one — they’ve never been able to coalesce around a piece of actual legislation.
And the bills that are most popular among Republicans don’t actually protect sick people. During the repeal-and-replace debate in 2017, for example, the leading replacement bill would have increased the number of uninsured by 23 million over a decade. For the sick, deductibles would have gone up, not down.
The Affordable Care Act exchanges
In the meantime, the Trump administration is trying to sabotage the exchanges. A new rule that took effect last month will exploit a loophole in the law allowing for the sale of “short term” health plans.
Originally meant to serve as a stopgap for those with temporary breaks in coverage, short-term plans discriminate against people with pre-existing conditions and usually exclude vital protections, including prescription drugs and maternity care. They’re cheap — but you get what you pay for.
Now, under the new rule, plans that last for 364 days out of 365 can qualify as “short term.” As relatively healthy people who like the low price tag leave the exchanges to buy short-term coverage, the pool of people left on the exchanges will be relatively sicker. Prices will surge by an average of 18 percent in most states, according to researchers at the Urban Institute.
Already, unscrupulous brokers are using high-pressure tactics to sell short-term plans over the phone. Internet searches for “Obamacare plans” or “ACA enroll” will usually direct people to brokers selling short-term plans, not comprehensive coverage. Many of those people will be in for a rude shock when they get sick and discover how little their insurance actually covers.
There’s more. Earlier this year, a low-profile rule change reduced the subsidies for people who buy health insurance through the exchanges. President Trump’s own health officials recommended against the change because it “would cause coverage losses, further premium increases, and market disruption.” But the White House approved the cut anyway, and 70,000 people are expected to lose coverage as a result.
Insurance for the poor
At the same time, the Trump administration is laboring to tear health care from the poor. In its most galling move, it has been allowing states to add work requirements to Medicaid. To date, 18 states (most Republican controlled) have sought to impose work requirements, though Kentucky is likely to drop the request after Gov. Matt Bevin’s apparent loss last week.
Work requirements poll well: If you’re getting benefits on the government’s dime, shouldn’t you be expected to pull your own weight? But they are a policy nightmare. Fully 60 percent of those who are subject to work requirements already work. Of those who don’t, the overwhelming majority are in school, disabled or caring for dependents. There just aren’t that many people on Medicaid who can work but have chosen not to.
That’s why work requirements can’t stimulate much new employment. Every Medicaid beneficiary who’s subject to the requirements, however, has to jump through the bureaucratic hoops of attesting to their work status. Desperately poor people who lack the bandwidth or the wherewithal to comply will lose health coverage because they can’t manage the paperwork.
Experience in Arkansas bears the point out. More than 18,000 people, or nearly one in four Medicaid beneficiaries subject to work requirements, lost coverage in the first seven months of the program. A careful study in the New England Journal of Medicine found that “lack of awareness and confusion about the reporting requirements were common.” Employment rates didn’t budge.
Losing Medicaid isn’t a pathway out of poverty. It’s a pathway to destitution. A randomized trial out of Oregon, for example, shows that getting Medicaid eliminated catastrophic medical bills and cut in half the rates of people who had to borrow money or skip other bills to pay for health care. Recent research also shows that Medicaid sharply reduces evictions.
Attacks on the poor go beyond work requirements. For decades, Title X has offered grants for family planning services — including contraception and screenings for sexually transmitted diseases — for low-income women and families. In February, however, the Trump administration eliminated funding for any organization that refers patients for abortions.
The change was a deliberate effort to target Planned Parenthood, which, through its large network of clinics, serves about 40 percent of the women receiving help through Title X. Planned Parenthood has since withdrawn from the program, with the predictable result that poor women, especially those in rural areas, will face new barriers to receiving care.
Mr. Trump is even using health care as a weapon in his immigration war. Most legal immigrants are eligible for Medicaid once they’ve lived in the United States for more than five years, and millions have enrolled. But in a new “public charge” rule, originally set to take effect this month, the administration said that it would start denying citizenship to immigrants who are on Medicaid.
The courts have enjoined the rule for now; one judge said it was “repugnant to the American dream.” If the rule takes effect, however, millions of poor immigrants — every one of whom is legally present in the United States — will lose coverage.
So ignore what the Trump administration says. Pay attention to what it’s doing. It’s working to eliminate protections for the sick, destabilize the exchanges, and strip insurance from the poor. That’s the ugly truth.
A lot of conservatives with big platforms were very, very angry at Trump this week.
If the government shuts down tonight over President Donald Trump’s demand for $5 billion for a border wall, feel free to blame conservative punditry.
This week Ann Coulter described Trump as a gutless “sociopath” who, without a border wall, “will just have been a joke presidency who scammed the American people.”
Radio host Rush Limbaugh said on his show Wednesday that without the $5 billion, any signing of a budget stop gap would show “Trump gets nothing and the Democrats get everything.”
Fox & Friends co-host Steve Doocy said that without wall funding, “the swamp wins,” adding that Trump will “look like a loser” without wall funding and stating, “This is worth shutting down” the government.
There’s no way around it: A lot of people on the right are very upset with Trump (and each other) right now. And they’re taking it out on the president — on his favorite television network, on talk radio, on podcasts, and online — and it’s worked to put the pressure on him. Trump has abruptly changed course to demand $5 billion for a border wall (a demand the Senate isn’t likely to give in to). And now the government is facing a “very long” shutdown.
In the words of Sen. Bob Corker (R-TN), referring to Coulter and Limbaugh, “We have two talk-radio show hosts who basically influenced the president, and we’re in a shutdown mode. It’s just—that’s tyranny, isn’t it?”
.. Republican voters are still solidly behind Trump (his approval rating among Republicans polled by Gallup is at 86 percent). But unlike some portions of Trump’s base, the voices of the party who supported Trump because of what he could do as president rather than who he is as president are deeply displeased with him.
Some on the right are upset about the administration’s decision to pull out of Syria and, perhaps, Afghanistan — and are very worried by news of James Mattis’s resignation from his role as defense secretary.
Others are angry that more than two years into Republican control of all three branches of the federal government, Planned Parenthood still hasn’t been fully defunded. Then there’s that executive order banning bump stocks. And the continued existence of Obamacare.
.. But this week, many of the right’s biggest names were more or less united on one particular issue, with Fox News pundits and some of Trump’s most important surrogates and supporters leading the way: build a wall, or you’re done. As Fox News’s Laura Ingraham said on her show Wednesday night, “Not funding the wall is going to go down as one of the worst, worst things to have happened to this administration.”
.. They urged a government shutdown (and even the closing of the United States’ border with Mexico) in full knowledge that Trump was listening, even as Republican senators prepared to fly home for the holidays with no expectations they’d need to be present for a vote to keep the government open.
House Freedom Caucus Chair Mark Meadows said Wednesday that Trump’s “base will go crazy” if border wall money wasn’t provided in the stopgap government funding measure, and he was joined by Rep. Jim Jordan (R-OH), who tweetedabout wall funding with the hashtag #DoWhatWeSaid.
That same day, Ann Coulter published a syndicated piece titled “Gutless President in a Wall-Less Country,” in which she wrote that contrary to what some might believe, many of Trump’s supporters were well aware that he was a “gigantic douchebag.” She wrote, “If anything, Trump’s vulgar narcissism made his vow to build a wall more believable. Respectable politicians had made similar promises over the years — and they always betrayed the voters. Maybe it took a sociopath to ignore elite opinion and keep his word.”
But she added, “Unfortunately, that’s all he does: talk. He’s not interested in doing anything that would require the tiniest bit of effort.”
That piece may have gotten her unfollowed on Twitter by the president. Then she went on the Daily Caller’s podcast to say that the entire purpose of Trump’s presidency appears to be “making sure Ivanka and Jared can make money.” But by Wednesday evening, Trump was arguing that the wall would in fact be built, “one way or the other,” saying that perhaps the military could construct it.
On Thursday, Trump said during a signing ceremony for the farm bill that “any measure the funds the government must include border security,” but added, that the wall is “also called steel slats, so that I give them a little bit of an out — steel slats. … We don’t use the word ‘wall’ necessarily.”
That same day, Rush Limbaugh said on his radio show that Trump had contacted him and said, “if whatever happens in the House and Senate comes back to him with no allocation of $5 billion for the wall, then he’s going to veto it.” But that doesn’t seem to have soothed many of conservative media’s loudest voices, like Coulter, who tweeted a “border wall construction update” on Friday: “Miles completed yesterday–Zero; Miles completed since Inauguration–Zero. NEXT UPDATE TOMORROW.” (For the record, border wall replacement is already taking place, and new construction is slated for next year.)
That’s because contrary to popular opinion, many on the right who voted for Trump, particularly in conservative media, didn’t vote for a personality. As Coulter put it in her column, “The Washington Post loves to find the one crazy, trailer park lady who supports Trump because she’s had religious ecstasies about him, but most people who voted for him did so with a boatload of qualms.”
Rather, they had specific reasons for voting for Trump.
- Getting out of foreign wars, for example, or
- ending Obamacare, or
- curbing abortion. Or, most importantly for many,
- curtailing immigration and
- building a border wall.
And they aren’t seeing much progress. And they’re not happy about it.
I reached out to Coulter, and asked her if her support for Trump was contingent on a wall, or whether toughened border security would be enough. She responded via email: “WALL — or whatever Israel has,” with a link to a Jerusalem Post article about Israel’s border security mechanisms, adding “definitely NOT a B.S., completely meaningless promise of “border security.”