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.
The administration’s chaotic reversals on Obamacare could deprive millions of coverage.
Meanwhile, the administration’s latest budget, released in mid-March, stands behind legislation known as “Graham-Cassidy,” which was pushed by Republicans in 2017 but never won enough support to be brought to a vote.
The Trojan horse of health care reform, the proposal provides for relatively small initial cuts in federal funding and then huge reductions starting in 2027.
According to a Brookings Institution report, Graham-Cassidy would cost 32 million Americans their health insurance by 2027, just as full repeal would. That’s Donald Trump’s idea of a “beautiful,” “terrific” and “unbelievable” health care plan.
.. The administration’s recent decision to submit a brief in a Texas case asking the court to declare all of Obamacare unconstitutional was well publicized.
Slipping by almost unnoticed was Mr. Trump’s instruction last June to the Justice Department, which was defending the A.C.A., to argue instead that certain key provisions — notably, the requirement that Americans with pre-existing conditions be treated equally — be declared unconstitutional.
A win by Mr. Trump in this case could mean that nearly 20 million Americans would lose insurance, according to the Urban Institute.
The basic economics of U.S. health care makes that easier said than done. Before the ACA, the U.S. stood out from the international pack on health care in two very unpleasant ways. First, it spent a far larger share of gross domestic product on health care. Second, it was the only advanced industrial nation that left vast swaths of its population uninsured. These two doleful facts remain true, although the fraction of Americans without health insurance fell from 13.3% in 2013 to 8.8% in 2017, according to Commerce Department data.
There are several ways to get more people covered. One is to adopt a system in which the government provides or pays for universal coverage—the British or Canadian model. This won’t happen soon in the U.S., not even as Medicare for All.
A second route, advocated unsuccessfully by President Clinton in 1993, is to mandate that every employer provide health insurance to its workers. This approach might seem natural in the U.S. context because so many workers already receive health insurance that way. But the employer mandate has fatal flaws. It wouldn’t cover the nonworking population, and it would impose heavy burdens on small businesses.
For these and other reasons, many economists in the Clinton administration—including me—favored an individual mandate. But that idea was dead in the water in 1993 because it had been advocated by the Heritage Foundation starting in 1989. It was therefore a “right wing” idea.
There are problems with an individual mandate, too. For one, the high cost of U.S. health insurance means that many low- and moderate-income families cannot afford to buy policies on their own. For another, if for-profit insurance companies are made to lose money by covering people with pre-existing conditions, the government must also force young healthy people, who tend to have limited medical expenses, into the insurance pool.
Fortunately, both problems are easily solved—conceptually, that is, not politically—by mandating that everyone buy a policy and providing subsidies to the needy. Massachusetts legislators understood this in 2006. They also knew they were not writing on a blank slate; many citizens received health insurance through their jobs and didn’t want to lose it. Hence the hybrid system that became known as RomneyCare.
If this short description reminds you of the ACA, it should. The two plans are not identical twins, but there is a family resemblance. In 2010 Democrats didn’t follow in the footsteps of Romney Republicans to make them look good; they designed their plan that way because under the constraints of precedent, the underlying logic practically forces you there.
Keep that in mind: If there ever is a TrumpCare, an unlikely proposition, it’s bound to resemble RomneyCare and ObamaCare—no matter what the president claims.
As long as I’ve covered politics, Republicans have been trying to scare me.
Sometimes, it has been about gays and transgender people and uppity women looming, but usually it has been about people with darker skin looming.
They’re coming, always coming, to take things and change things and hurt people.
A Democratic president coined the expression, “The only thing we have to fear is fear itself.” But it was Republicans who flipped the sentiment and turned it into a powerful and remorseless campaign ethos: Make voters fear fear itself.
The president has, after all, put a tremendous effort into the sulfurous stew of lies, racially charged rhetoric and scaremongering that he has been serving up as an election closer. He has been inspired to new depths of delusion, tweeting that “Republicans will totally protect people with Pre-Existing Conditions, Democrats will not! Vote Republican.”
He has been twinning the words “caravan” and “Kavanaugh” in a mellifluous poem to white male hegemony. Whites should be afraid of the migrant caravan traveling from Central America, especially since “unknown Middle Easterners” were hidden in its midst, an alternative fact that he cheerfully acknowledged was based on nothing.
The word “Kavanaugh” is meant to evoke the fear that aggrieved women will hurtle out of the past to tear down men from their rightful perches of privilege.
Naomi Wolf told Bill Clinton, and later Al Gore, they should present themselves as the Good Father, strong enough to protect the home (America) from invaders.
Is there an election coming up, or something?
With Republicans struggling to keep their grip on Congress, President Trump is dialing up the demagogy. At campaign rallies and on social media, he’s spewing dark warnings about a
- Democratic mob clamoring to usher in an
- era of open borders,
- rampant crime,
- social chaos and
- economic radicalism.
As is so often the case, Mr. Trump is not letting reality interfere with his performance. At a rally in Nevada this weekend, the president told the crowd that Californians were rioting to “get out of their sanctuary cities.” (They aren’t.) He also suggested that Democrats will soon be looking to hand out free luxury cars to illegal immigrants. (They won’t.) “Give ’em a driver’s license. Next thing you know, they’ll want to buy ’em a car,” he riffed. “Then they’ll say the car’s not good enough, we want — how about a Rolls-Royce?”
Mr. Trump’s Twitter feed has been electrifying as well, full of statements intended to thrill his fans — and, better still, bait his opponents into a partisan rage. In recent days, he has dubbed Stormy Daniels “Horseface,” escalated his taunting of Senator Elizabeth Warren as “Pocahontas” and grumbled about the fact that Bruce Ohr, one of Mr. Trump’s nemeses in the “rigged” Russian “witch hunt,” is still employed by the Department of Justice. He has asserted that the Democratic nominee for governor in Florida, Andrew Gillum, is looking to turn the state into “the next Venezuela.” He has threatened to dispatch troops to shut down the southern border and renewed his vow to cut off the “massive foreign aid” sent to El Salvador, Guatemala and Honduras for those nations’ failure to stop their people from flocking to the United States.
In particular, the caravan of Honduran migrants making its way north has emerged as a focus of his fantasies. Mr. Trump has repeatedly implied that Democrats are paying Honduran youth to join the caravan. On Monday, he claimed, based on nothing, that the caravan is awash in “criminals and unknown Middle Easterners.”
.. Mr. Trump plays the polarization game because he enjoys it — he does love a brawl — and because he doesn’t appear to care about much beyond his political and personal fortunes. And, more practically speaking, these days he doesn’t have much else to talk about.
It’s not that this president has failed to achieve anything in his first couple of years in office. The economy is chugging along right now, and many Republican candidates would be happy for him to play that up on the campaign trail.
But his most notable achievements do not resonate beyond Mr. Trump’s base. He has overseen a conservative overhaul of the federal judiciary, seating a record number of judges, including two Supreme Court justices. And he has been an aggressive deregulator in areas ranging from education to transportation to health care to the environment.
They seek to restore access to a middle-class life by providing decent, well-paying jobs, reestablishing a sense of financial security, and ensuring access to quality education – without the chokehold of student debt that so many graduates currently face – and decent health care, regardless of pre-existing medical conditions. They call for affordable housing and a secure retirement in which the elderly are not preyed on by an avaricious financial sector. And they seek a more dynamic, competitive, and fair-market economy by curbing the excesses of market power, financialization, and globalization, and by strengthening workers’ bargaining power.
These perquisites of a middle-class life are attainable. They were affordable a half-century ago, when the country was substantially poorer than it is today; and they are affordable now. In fact, neither America’s economy nor its democracy can afford not to bolster the middle class. Government policies and programs – including public options for health insurance, supplementary retirement benefits, or mortgages – are crucial to realizing this vision.
.. In a normal democracy, these ideas would, I am confident, prevail. But US politics has been corrupted by money, gerrymandering and massive attempts at disenfranchisement. The 2017 tax bill was nothing short of a bribe to corporations and the wealthy to pour their financial resources into the 2018 election. Statistics show that money matters enormously in American politics.
But it’s what the bill doesn’t say that makes the above mostly meaningless.
Yes, insurance companies wouldn’t be allowed to refuse to offer coverage to someone who, for example, has a history of cancer or is pregnant. But they could sell someone a policy that doesn’t cover cancer treatments or the birth of a child.
Sure, premiums wouldn’t be allowed to vary based on health status or pre-existing conditions. But prices could dramatically vary based on age, gender, occupation and other factors, including hobbies, in ways that are functionally the same as basing them on medical histories. Insurance companies have a lot of experience figuring out that stuff.There’s no need to speculate about how insurance companies would respond to this, because this is how the system worked for people who bought individual policies before the Affordable Care Act. Insurers don’t make money paying claims; they make money by avoiding claims or refusing the pay them. If they’re allowed to keep the most expensive people and treatments off their books, they will.
Before the Affordable Care Act, it already was illegal for health insurance companies to reject customers with pre-existing conditions or charge them more based on their medical histories if they got coverage through a group plan, like from an employer. And insurers and employers are limited in how much they could refuse to pay for treatments related to a pre-existing condition for group policyholders. The Affordable Care Act extended similar protections to people who buy their health insurance directly or via the exchanges the law created.
.. With Obamacare repeal off the legislative agenda ― for now, at least ― why would these senators write legislation to solve a problem that doesn’t exist? Because their party is the middle of unsolving it... The administration, however, doesn’t want to throw out the whole law ― just the parts that protect people with pre-existing conditions.