Many of the conservatives most engaged in the details of health care in recent years, meanwhile, thought its credit was not well designed to allow most people to obtain at least catastrophic coverage
.. Many of the conservatives most engaged in the details of health care in recent years, meanwhile, thought its credit was not well designed to allow most people to obtain at least catastrophic coverage.
.. The great bulk of the relative coverage loss that the agency projects is a function of three core assumptions. First, it assumes that well over 10 million Americans now buy coverage only because they don’t want to pay the individual-mandate penalty and simply wouldn’t buy any insurance absent a penalty. Second, it assumes that Medicaid spending growth will accelerate much faster than overall health spending in the coming years
.. The great bulk of the relative coverage loss that the agency projects is a function of three core assumptions.
- First, it assumes that well over 10 million Americans now buy coverage only because they don’t want to pay the individual-mandate penalty and simply wouldn’t buy any insurance absent a penalty.
- Second, it assumes that Medicaid spending growth will accelerate much faster than overall health spending in the coming years
- And third, it assumes that letting insurers have much more latitude to offer people different kinds of insurance products (including coverage with premiums equal to the new tax credit they could receive) would not result in significant numbers of new insurance products that could appeal to consumers.
.. Most conservative health-reform plans in recent years proposed to make an individual mandate unnecessary by using “continuous coverage” protections
.. a 30 percent surcharge on the premiums of people who have been without coverage for more than three months. This is certainly an inadequate spur to get covered, and indeed it would tend to discourage healthier people from getting insured.
.. it does not do enough to enable people with incomes just above Medicaid eligibility to purchase attractive coverage.
.. The House Republican proposal has clearly been designed with a very specific set of assumptions in mind about what can make it past the Byrd rule in the Senate, and these assumptions account for most of the bill’s peculiar features
.. They also account for much of the bill’s trouble both with Republican members of Congress and with the CBO.
.. a repeal of the law’s taxes, mandates, and subsidies that left in place its regulations would leave far more people uninsured than would a complete repeal that also eliminated the law’s insurance rules. This is because eliminating those regulations would let insurers offer more-varied products and give them a better chance of surviving in the individual market. The same is surely true regarding the House Republican bill: If it repealed more of Obamacare, it would help more people get covered.
.. the House Republican bill occupies an untenable middle space between two more-plausible approaches to conservative health-care reform.
.. On the one hand, House Republicans might conclude that it is not their job to solve procedural problems in the Senate and then proceed with a bill that aggressively rolled back Obamacare’s regulations and replaced them altogether. Such a bill would return nearly all insurance regulation to the states and subsidize catastrophic coverage (with continuous-coverage protection and a credit more generous at the bottom) in a way that enabled everyone in the individual market to afford at least that much.
The Case Against the CBO
That criticism is correct, and Republicans should make alterations so that a lot more people get covered. But the criticism is also exaggerated.
.. But the CBO has gotten its estimates badly wrong before. Before Congress enacted Obamacare, the office projected that by this year, its exchanges would enroll 23 million people. As late as June 2015, the CBO was sticking to this projection. The actual number is about nine million.
.. Its report then added, “Most of those reductions in coverage would stem from repealing the penalties associated with the individual mandate.”
.. If this is right, the implication is that many people who would “lose” coverage after the partial repeal of Obamacare would be better described as people who would drop their coverage. They are buying it only to avoid the fines, and do not think their coverage is worth what they are paying for it... But would millions of people really leave Medicaid if the fines ended? Would they really, that is, stop taking advantage of a free program?.. If you’re a health-policy staffer for a leading congressional Republican, advocating for more generous tax credits for people with low incomes would require taking on conservatives who object to progressivity. And even if you win that fight, the CBO might still say that coverage will decline substantially without the individual mandate.
Conservative Fantasies, Colliding With Reality
Many have a distorted view of the numbers. For example, people have a vastly exaggerated view of how much we spend on foreign aid. Many also fail to connect their personal experience with public policy: Large numbers of Social Security and Medicare recipients believe that they make no use of any government social program.
.. But the reality is that the proposed cuts would have ugly, highly visible effects. Zeroing out the Community Development Block Grant program may sound good if you have no idea what it does (which Mr. Trump surely doesn’t); eliminating Meals on Wheels, an immediate consequence, not so much. Nor would coal country, which voted overwhelmingly for Mr. Trump, like the consequences if he eliminates the Appalachian Regional Commission.
.. Republicans’ budget promises, like their health care promises, have been based on an essentially fraudulent picture of what’s really going on. And now the bill for these lies is coming due.
The Politics of the AHCA
This is the party, after all, that just a few months ago lost the presidency to the most unsuitable, unfit, unappealing major-party candidate in American history, and has spent most of the time since then blaming Russia for its own ineptitude.
.. Neoliberal, managerial, centrist globalism is being challenged by populists of the anti-liberal right and left. Right now, the right-wing variant holds power in Washington. If Trump had the guts to combine his populist-nationalist appeals with support for a single-payer health-care system, he just might succeed in realigning both major American parties by scrambling their policy commitments.
.. Maybe he’s gambling that for the bulk of his voters, making sure they aren’t paying for insurance for the “undeserving” is precisely the point.
.. Meanwhile, by 2020 the state of the economy and job growth is what will really matter to voters, or at least an electoral college majority thereof.
.. It would normally be strange for a Republican president to want his own party’s majority to suffer a major black eye like that. But this is Ryan’s bill, and Trump has no love for Ryan.
.. Moreover, inasmuch as Bannon is in competition with Ryan-ally and Chief of Staff Reince Priebus for influence over the White House’s agenda, it’s very much in his interest specifically for Ryan to fail. The collapse of the AHCA would be a massive failure — and would likely invite a leadership challenge.
.. And if it failed quickly, it would be easy for Trump to blame Ryan for getting it wrong, tinker with ObamaCare around the edges (particularly in ways that could be done without even passing legislation), and then when the exchanges don’t collapse claim he fixed them.
.. Trump could yell at a bunch of insurance executives, watch premiums stabilize, and claim victory.
.. The most exotic possibility is that Trump not only wants the bill to fail and Ryan to take the blame, but that he wouldn’t be too upset to see the Freedom Caucus defanged
.. There are certainly people in Trump’s inner circle who see the big problem with ObamaCare as being its support of private insurers, and who would prefer a relatively stingy single-payer plan to either ObamaCare or ObamaCare light. Trump doesn’t have a legislative majority for a reform like that — but maybe after some strategic losses in 2018 he would?
.. it is important to recognize that Trump’s position is far less exposed than Ryan’s is.
.. the dominant political fact about the Trump presidency. He won by attacking his own party’s leadership. He can’t win again without retaining the support of the Republican base — which means he has to be supportive of any effort to repeal ObamaCare, because the base has demanded that for years. But he will take every opportunity to convince that same base that they should be more loyal to him than to a GOP leadership for which they have already demonstrated mistrust. Which means failures by that leadership can be turned to his advantage.