Health care omnibus

So, I was reading this NYT article last night about how conservatives are getting really worried about ACA repeal and are starting a new hard push to get their damn repeal.  Why do the Koch brothers hate people have health insurance so much anyway?  Seriously?  Anyway, reminded me that there’s a number of health care related items recently I’d been meaning to post on, so here you go:

1) Sarah Kliff on the lack of guidance from Trump’s speech:

All of these things are controversial, all offend various stakeholders and please others, and each will provoke a major fight in Congress. Presidential guidance can help steer his party’s legislative path and minimize conflicts on these points. But Trump offered little to none.

Effectively, this was a punt back to Ryan:Trump is not going to step in and help him get the caucus in line. The result will be months more of wrangling over repeal options, with no clear path to passing anything.

2) Ezra Klein on how much Republicans have actually moved to the left on health care:

In some ways I can’t believe how much they have moved,” says Nancy-Ann DeParle, who served as President Obama’s top health aide during the Affordable Care Act’s passage. “They have moved to adopt our goals of getting everyone covered, reforming the worst abuses of underwriting such as preexisting condition exclusions, allowing children to stay on their parents’ plans until they are 26, etc.”

As consequential as the GOP’s movement on the policy is, the bigger change is that Republicans are now prioritizing health reform. It is unimaginable, absent Obamacare, that a newly elected Republican president would make passing refundable tax credits to increase insurance coverage his top priority. The GOP is, and remains, deeply divided on health care, and much more committed to tax cuts.

3) Dave Leonhardt on the Republicans troubles:

Let’s start with reality. Republican leaders are now paying the price for their dishonest approach to fighting Obamacare.

To be clear, there are honest conservative attacks to make on Obamacare. Republicans could have said that Americans who can’t afford health insurance aren’t entitled to it, just as people are not entitled to own a home. Or Republicans could have tried to alter the law — say, with less generous insurance plans.

But Republican leaders chose the easy political route instead. They blamed Obamacare (sometimes fairly, mostly not) for almost every health care problem. They’ve promoted the same fallacy for which conservatives often mock liberals: the free-lunch fallacy.

There is no free lunch on health care. Your health “costs” pay for my health “benefits,” and vice versa. If Trump promises a less expensive system, he is also promising to eliminate some care.[emphasis mine] He could cut wasteful care — and should — but Republicans caricatured the Obama administration’s attempts as “death panels” without offering their own steps.

Now that they’re running the government, free-lunchism has consequences. Their promise to scrap taxes on the wealthy, for example, leaves them without money to cover people. That’s why the independent Congressional Budget Office keeps concluding that the various Obamacare replacement plans would deprive millions of people of insurance.

4) Really, really good piece from Ron Brownstein on the big problems created as Republicans try to reduce risk-sharing:

The problem is that the Republican plans eliminate the ACA’s requirement that all insurance policies provide robust minimum benefits like hospitalization and maternity care. Under a continuous-coverage system, that means healthy people could buy inexpensive skeleton plans and only shift to more inclusive coverage when they get sick, knowing that insurers must sell it to them. Christine Eibner, a senior Rand Corporation economist, said that scenario may prevent insurers from offering comprehensive plans to anyone on the individual market, because the only people buying them would be those with greater health needs. “You have a significant risk that this [entire] insurance market becomes bare bones,” she said.

That risk is compounded by another key GOP proposal: allowing any insurance policy approved in one state to be sold in any state. The ACA already allows interstate sale when all the affected states agree. But no insurer or state has pursued such cross-border sales, largely because out-of-state companies can’t easily compete with local insurers in building an affordable network of doctors and hospitals.

By eliminating minimum benefit requirements, though, the GOP proposals change the equation. The GOP plans would allow an insurer from a lightly regulated state to offer a low-benefit, low-cost plan that peels away younger and healthier consumers in states that require more complete coverage. If only those with greater health needs were left to buy the comprehensive coverage in more regulated states, medical costs would skyrocket—again raising the risk that no insurer would even sell such comprehensive coverage.

Health-savings accounts, another GOP mainstay, would further unravel risk sharing. Those tax-free accounts, which consumers can use to pay medical costs directly, appeal most to healthy people with fewer bills. If healthy people abandoned comprehensive insurance for such accounts, the families with greater needs left behind would again face rising costs and diminished availability of adequate coverage. GOP proposals to allow greater age variation in premium rates push in the same direction.

Reflecting the parties’ larger philosophical divide, the Republican plans prize choice and autonomy while the ACA stresses solidarity. But the practical effect of the GOP alternatives is to advantage the young and healthy over the old and sick. That’s an uncomfortable equation for a Republican Party now preponderantly reliant on the votes of older whites. In health reform, the toughest challenge for Republicans may be upholding the Hippocratic oath—first, do no harm—for their own voters.

5) Josh Barro on the Republican quandary:

The basic political problem he faces is simple: Republicans are in agreement that Obamacare should be repealed and replaced, but their agreement breaks down over what it should be replaced with.

A bill that keeps too much of Obamacare’s spending will alienate conservatives who believe they were sent to Washington to pass a “full” repeal. A bill that cuts too much makes moderate Republicans squeamish, especially those who come from states that depend on expanded Medicaid…

The discussion draft House bill that leaked last week would most likely have been unacceptable to both Paul and Murkowski — handing out too many subsidies for his taste and cutting spending on Medicaid too much for her standards.

This makes me think it’s very unlikely that a bill that can be rammed through the House can also pass the Senate — and therefore that it is unlikely that Ryan’s strategy will lead to enactment of legislation.

But maybe that is what Paul Ryan is up to.

As Brian Beutler of the New Republic notes, forcing a bill down the throats of House Republicans only to see it die in the Senate is not an effective strategy for repealing Obamacare. But it could be a very effective strategy for getting conservative voters to blame the Senate, not the House, for Republicans’ failure to repeal Obamacare.

6) And last, should Republicans actually have a single proposal come to light, there is huge cost-shifting as compared to ACA.  Away from poorer people towards older people.  Kaiser Family Foundation captures this in some nice charts:

Figure 1: How House Republicans’ health reform plan might shift average health insurance tax credits, based on income and age, in 2020

And a final really, really important point.  Republican tax credits are all planned to grow significantly slower than medical inflation (which pretty much always outstrips regular inflation).  So, gradually, over time, the plan is to do less and less to see that Americans can have affordable health care.  Presumably, should an actual plan come out, Democrats will be smart enough to have a good and thorough message on that.  Oh, and also, note, that Republicans are really not fans of people being able to afford health care.

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About Steve Greene
Professor of Political Science at NC State http://faculty.chass.ncsu.edu/shgreene

6 Responses to Health care omnibus

  1. Jon K says:

    The push to eliminate the requirement to make sure that insurance plans actually cover expensive medical conditions terrifies me. I remember preobamacare insurance in the individual market. It had $2,000 caps on name brand prescription drugs and $1 million lifetime benefit cap.

    For someone like me, with a lifelong chronic condition, that is worthless insurance. It won’t pay for my treatment. What is the point of having health insurance that won’t pay your legitimate medical bills? What do they expect people like me to do?

    If I can’t get my medications then I am disabled and will require full government support. I am also miserable with zero quality of life. How does that benefit anyone?

    • Jon K says:

      Ironically, if they were to force me onto disability due to worthless insurance, then I would get Medicare, which would pay for my treatment. It would just permanently remove me from the workforce.

      Sounds like an awesome idea right?

    • Steve Greene says:

      Clearly it’s your fault they you have a life-long chronic condition. Just because we are a common society is no reason you should be able to leech off the superior people ;-).

  2. rgbact says:

    Koch Brothers? ACA is the least popular govt program ever. Probably better off figuring out why, rather than resorting to “Koch Bros” deflections

    Lots of R senators from states getting lots of free Medicaid money. Not sure how you work around that basic love of “free money” to pass anything that takes that away.

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