Failure to Rise to the Challenge of Reform

Last Friday, Republicans pulled the health care bill that would have replaced Obamacare and fulfilled their mission of repealing it after many promises to do so during Trump’s presidency. The Grand Old Party’s plan would have replaced Obama’s system of income-based subsidies with one of age-based tax credits, which recipients would use to buy insurance on the private market. Proponents argued that the bill would stimulate the development of the private insurance market, cut the federal deficit, and restore individual agency in health care decisions. Opponents on the left argued that the wealthy would receive substantial tax cuts, and premiums would rise for the poor. Opponents on the right contended that the plan was simply “Obamacare-Lite” and did not do enough to move health insurance from the public sphere.

With some revisions, the GOP plan could establish a stable insurance market and the expectation of some government assistance with health care coverage costs. How it could offer adequate coverage to low-income health care customers—especially older ones—remains painfully unclear. Its passing would have undermined the ideological notion of health care as a human right since it neither guarantees nor insists that all citizens be adequately covered or even covered at all. Its failure reflects the challenge of creating comprehensive health care reform in a divided legislature riddled with competing interests, rather than any true affirmation of a citizens’ right to health care.

According to the Congressional Budget Office, Trumpcare would cut an estimated $337 billion from the federal deficit between 2017 and 2026. That money comes from reductions in projected Medicaid spending over those nine years and the fact that Trump’s tax credits generally offer less federal assistance for non-group health insurance than Obama’s (non-group insurance refers to insurance for those not covered by an employer or Medicaid). Although the plan saves federal dollars spent on health care, it doesn’t promise equal health care at a lower cost. Read another way, much of that $337 billion is money that simply will no longer be used for health care at all.

Indeed, under Trumpcare, average non-group health care premiums would be 10 percent lower than under Obamacare by 2026. Part of those savings stem from federal assistance, largely from the Patient and State Stability Fund, which would grant money to states to offset the cost to insurance companies of unusually high claims. The drop in premiums is also due to a loosening of restrictions on what an insurance company is required to cover. Obamacare mandates a minimum “package” of 10 benefits for all private insurance plans: outpatient care, emergency services, hospitalization, maternity, mental health and substance abuse, prescription drugs, rehabilitation services, lab work, preventative care, and pediatric services. Trump’s plan gives that authority to state governments, which could weaken mandates in red states. The result of this would be an incentive for customers to buy less coverage at a lower price, one strengthened by reductions in federal aid. Unfortunately, this plan doesn’t consider the estimated 24 million people left uninsured in Trump’s plan by 2026. The fact that the plan made it as far as it did confirms that many people in this country conceive of health care as opt-in, rather than a guaranteed right or even an opt-out.

Illustration by Wayan Buschman

The plan also links quality of health care to socioeconomic status, despite what Obama did with Obamacare in attempt to dissociate the two. Under Obamacare, insurance is paid as a percentage of income, with subsidies covering the difference between that percentage and the cost of a person’s policy. The GOP bill‘s tax credits are largely based on age and aren’t tied to the price of insurance plans. They don’t vary with income except to exempt those in high income tax brackets. In conjunction with decreased Medicaid coverage, the result would be premium hikes for low-income people, especially older ones. Large businesses would no longer be required to provide health insurance, and insurance and pharmaceutical companies would receive tax breaks. Thus, Trump’s plan shifts the responsibility for health insurance from employers to employees while simultaneously making it more difficult for poorer employees to get insurance which, I suppose, isn’t surprising. Perhaps most importantly, the GOP plan highlights a very different analysis of health than that espoused by Obamacare. There is an understanding with Obamacare that health is a function not only of biological factors but also environmental ones. Obamacare acknowledges the association between poverty and general health costs through subsidies based on income and location. Often, the same low-income populations that would be unable to afford health insurance without federal assistance experience environmental injustices, such as living disproportionately close to toxic release facilities, lacking access to fresh produce, or working dangerous jobs. Unfortunately, the age-based credits of Trumpcare suggest that health is mostly biological. Under Obamacare, both populations pay the same percentage of their income for their coverage as anyone else, despite the likelihood of having higher health care claims—under Trumpcare, not so much.

What would the government do with savings from the implementation of Trumpcare? Trump’s budget proposal calls for an increase in military spending of $54 billion over the next fiscal year. Let’s say the military budget remains constant until 2026. The U.S. government would spend $432 billion more on the military than with its current budget, enough to offset health care savings and more. Trump has rationalized this shift by emphasizing the threat of international terrorism to U.S. security. If this is the case, we should be surprised to learn that jihadist terrorists have killed only 94 Americans since Sep. 11, 2001, and not one terrorist attack has been committed on U.S. soil by anyone from the countries in Trump’s immigration ban since 1975. Meanwhile, about 42,000 people a year die from suicide, 614,000 from heart disease, almost 600,000 from cancer, and about 55,000 from pneumonia or the flu, according to the Center for Disease Control and Prevention. 18 percent of the U.S. population suffers from anxiety disorders yet only about one third of those people receive treatment for it. More than just a defeat for Trump, last Friday revealed just how incongruent the U.S. budget remains. If the GOP offered to spend that $337 billion on mental health treatment, cancer research, flu vaccination, suicide hotlines, access to fresh food, or any of the myriad of possible preventative measures that would make health care less necessary, then maybe it would be worth it.

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