The basics of Republican health legislation, which haven’t changed much in different iterations of Trumpcare, are easy to describe: Take health insurance away from tens of millions, make it much worse and far more expensive for millions more, and use the money thus saved to cut taxes on the wealthy.
.. Meanwhile, taxes that fall mainly on a tiny, wealthy minority would be reduced or eliminated. These cuts would be big in dollar terms, but because the rich are already so rich, the savings would make very little difference to their lives.
More than 40 percent of the Senate bill’s tax cuts would go to people with annual incomes over $1 million — but even these lucky few would see their after-tax income rise only by a barely noticeable 2 percent.
.. So it’s vast suffering — including, according to the best estimates, around 200,000 preventable deaths — imposed on many of our fellow citizens in order to give a handful of wealthy people what amounts to some extra pocket change.
.. I think there are two big drivers — actually, two big lies — behind Republican cruelty on health care and beyond.
First, the evils of the G.O.P. plan are the flip side of the virtues of Obamacare. Because Republicans spent almost the entire Obama administration railing against the imaginary horrors of the Affordable Care Act — death panels! — repealing Obamacare was bound to be their first priority.
.. Republicans, through their political opportunism and dishonesty, boxed themselves into a position that makes them seem cruel and immoral — because they are.
.. this story began with a politically convenient lie — the pretense, going all the way back to Ronald Reagan, that social safety net programs just reward lazy people who don’t want to work. And we all know which people in particular were supposed to be on the take.
.. What it does — punish the poor and working class, cut taxes on the rich — is what every major G.O.P. policy proposal does. The only difference is that this time it’s all out in the open.
.. remember this moment. For this is what modern Republicans do; this is who they are.
How Did Health Care Get to Be Such a Mess?
The insurance company model drives up prices and fragments care. Rather than rejecting this jerry-built structure, the Democrats’ Obamacare legislation simply added a cracked support beam or two. The Republican bill will knock those out to focus on spackling other dilapidated parts of the system.
.. the leaders of the American Medical Association saw early health care models — union welfare funds, prepaid physician groups — as a threat. A.M.A. members sat on state licensing boards, so they could revoke the licenses of physicians who joined these “alternative” plans. A.M.A. officials likewise saw to it that recalcitrant physicians had their hospital admitting privileges rescinded.
.. President Harry Truman proposed a universal health care system, and archival evidence suggests that policy makers hoped to build the program around prepaid physician groups.
The Unfreeing of American Workers
After all, America is an open society, in which everyone is free to make his or her own choices about where to work and how to live.
Everyone, that is, except the 30 million workers now covered by noncompete agreements, who may find themselves all but unemployable if they quit their current jobs; the 52 million Americans with pre-existing conditions who will be effectively unable to buy individual health insurance, and hence stuck with their current employers, if the Freedom Caucus gets its way; and the millions of Americans burdened down by heavy student and other debt.
Why It Matters How We Define ‘Insurance’
Some types of insurance charge people according to risk. Others don’t. On health care, Americans are caught between the two, Greg Ip writes
Republicans want to strip out the regulations in Obamacare that require some people—primarily the young, male and healthy–to pay more so that others–mostly the elderly, female and sick–pay less. Critics say Republicans don’t seem to understand that insurance means some people subsidize others.
.. Pure insurance covers only random perils. Predictable perils generally require higher premiums. Teenagers and people with speeding tickets have more accidents, so insurers charge them more. If they were forced to charge risky and safe drivers the same amount, the latter would then be subsidizing the former.
.. Social Security, for example, effectively requires younger, affluent, able-bodied workers and two-earner couples to subsidize older, less affluent and disabled workers and one-earner couples.
.. pre-Obamacare health insurance was more like car insurance. Insurers could charge more to those they expected to cost more: women, the elderly, those with pre-existing conditions, with the result that many of these people went without insurance.
.. Conservative Obamacare opponents fall into two camps.
- One opposes the principle of subsidies, either direct or indirect via regulations and mandates, and are relatively indifferent to swelling the ranks of the uninsured.
- The other wants to reduce the uninsured, but without distorting the structure of the private market that forces some people to overpay so that others can underpay.
.. This second group would scrap many of Obamacare’s underwriting restrictions, which would stabilize the market by allowing insurers to charge premiums commensurate with risk. Those who couldn’t afford coverage because of gender, age or other risk factors would receive refundable tax credits.
.. age explains 75% of the variation in health risks
.. insurers could still be prohibited from excluding pre-existing conditions for members or charging women more than men. So long as they could underwrite based on age, and so long as patients maintained continuous coverage (rather than buying it only when they got sick), insurers could still price coverage profitably.
.. a 60-year-old
.. premiums for such a person are typically $13,000
.. boost that subsidy to $10,900
.. “The revenue/subsidies required to make it work are massive—because they have to substitute for all the complex cross-subsidies,”