Read Indivisible’s May 26, 2017 explainer, “Is your Republican member of Congress lying to you about Trumpcare?” here.
THE HUMAN COST
(This Appendix was originally compiled on March 9, 2017. Selected commentary on specific topics—including New York and Trumpcare, Historical Context, General Discussion of the Bill, CBO Report Commentary, Impact on Medicaid, Impact on Health Care for Women, Impact on Deductibles, and Impact on States that Voted for Trump, and Additional Articles on Various Aspects of Trumpcare—follow this section.)
Writing from liberal and conservative perspectives, Paul Waldman and Jennifer Rubin examine what’s at stake, and why, as Keith Ellison recently said, “When Democrats lose, bad things happen to good people.”
Rubin writes, in How did the GOP come up with this awful health-care bill?,
The Affordable Care Act proceeded from the belief that the government needed to make sure most everyone had access to health-care insurance, meaning that those with preexisting conditions or insufficient income would get help. . . .
House Speaker Paul D. Ryan (R-Wis.) seemed to suggest on Thursday in his PowerPoint presentation that the very idea of risk-sharing (healthier people subsidize sicker people) was the problem. If he really means that, then taxpayers shouldn’t be helping to support a cost-shifting, risk-sharing system at all. Then again, taxpayers wind up paying for Medicaid and Medicare (people get more out than they ever pay in). Moreover, Ryan’s support for health-care savings accounts (HSAs) becomes hypocritical, because the taxpayer subsidizes pretax deposits. (HSAs benefit richer people with disposable money to deposit.) Does he want to cost-shift for the very poor (Medicaid), the elderly (Medicare) and the rich (HSAs) but not for the working poor and the middle class? That’s essentially what his plan does — which is a problem, because President Trump’s campaign was all about helping the working poor and the middle class. (Since this bill socks it to the older, poorer and sicker people, Trump doesn’t want his name on it. He has, however, embraced it, so Trumpcare it is.) [Emphasis added.]
Waldman writes, in The GOP’s guiding principle: You’re on your own,
Yesterday, Ryan staged one of his PowerPoint presentations on the Republican health-care plan, the kind that makes Washington pundits swoon about how wonky and smart he supposedly is. Here’s part of what he said:
“The fatal conceit of Obamacare is that we’re just going to make everybody buy our health insurance at the federal level, young and healthy people are going to go into the market and pay for older, sicker people. So the young healthy person’s going to be made to buy health care, and they’re going to pay for the person, you know, who gets breast cancer in her 40s, or who gets heart disease in his 50s … the whole idea of Obamacare is … the people who are healthy pay for the people who are sick. It’s not working, and that’s why it’s in a death spiral.”
Clever readers will realize that what Ryan is describing here is actually called “insurance.” First of all, the healthy and the sick aren’t different people; they’re people at different points in their lives. And the whole idea of insurance is that those who don’t need it at a particular moment are paying for those who do. By Ryan’s logic, homeowner’s insurance is crazy, because those whose houses weren’t destroyed by tornadoes are paying for those whose houses were destroyed. If you didn’t get into a car accident this month, your insurance premiums paid to repair the cars of people who did. What an upside-down world we live in. [Emphasis added.]
So the Republican health-care plan is, essentially, you’re on your own.
Brown, Theresa: The Moral Failing of Obamacare Repeal
House Speaker Paul Ryan and others would take mock offense at the idea that they’re willing to let people go without care, but it’s the unavoidable logic of their drive to undo Obamacare — the part that Republicans would rather not talk about, even as it drives them to ram through the legislation without debate.
People without insurance and little money are still going to need care, some of it very expensive. To deny these people care by restricting their access at the source — ambulances, emergency departments, hospitals — would reflect equity in a you-get-what-you-pay-for model. But the human cost of limiting health care to those who can pay would be higher than any of us should be willing to bear.
“I’m terrified — isn’t that crazy?” [Maryann] Hammers said. “My biggest source of stress right now isn’t the fact that I have incurable cancer. It’s the prospect of losing my insurance.”
I spend a lot of time talking to Obamacare enrollees like Hoover: people who struck out on their own — left a job, started a business, went back to school — after Obamacare. They felt empowered to do this because in the reformed individual market, insurers had to offer everyone coverage — and couldn’t charge sick people more.
And now, many of them are already beginning to rearrange their lives around the law’s uncertain future.
NEW YORK AND TRUMPCARE
In our NY-19 Congressional District:
1. There are currently 16,500 ACA Marketplace enrollees.
2. There are currently 76,417 ACA Medicaid enrollees.
3. 92,917 people are estimated to lose coverage if Trumpcare is enacted.
[Source for above data is here.]
According to the New York State Department of Health, implementation of Trumpcare will likely have the following effect on our state:
1. Over 1 million New Yorkers will face significant loss of health care.
2. Over $4.5 billion in costs will be shifted to states, counties, and safety net hospitals over the next four years increasing the tax burden on residents and putting countless healthcare providers in jeopardy.
3. At least $2.4 billion of these costs will be shifted to New York State annually beginning in 2020. This burden might grow even larger if the impact of Medicaid block grants is considered.
4. The $400 million in tax credits used by New Yorkers to purchase health insurance on the New York State of Health insurance exchange will be lost and replaced (only in some cases, not all) with alternative subsidies which are not related a person’s ability to pay.
HOW WE GOT HERE: THE HISTORICAL CONTEXT
Leonhardt, David: The Original Lie About Obamacare
How did the [Republican] party’s leaders put themselves in this position? The short answer is that they began believing their own hype and set out to solve a problem that doesn’t exist. . . .: saving America from a partisan, socialistic big-government takeover of health care.
To understand why that description is wrong, it helps to recall some history. Democratic attempts to cover the uninsured stretch back almost a century. But opposition to universal government-provided insurance was always too strong.
“We have to pass the bill,” [Pelosi] said, “so that you can find out what is in it — away from the fog of the controversy.”
Conservatives — abetted by dozens of political journalists who should have known better — immediately seized on a truncated version of the quote. Pelosi was really expressing her confidence in the underlying merits of the bill, but it became instead a shorthand for the allegedly dodgy process through which Obamacare was passed.
But Pelosi never said the bill was enacted in secret or under cover of night, because it wasn’t. She said it was enacted in a fog of controversy. The controversy, naturally enough, focused on the most contentious aspects of the bill rather than on the most broadly popular. Much of it was about misunderstandings or misconceptions — claims that the bill contained death panels or did nothing to restrain health care costs — rather than on the Affordable Care Act’s concrete benefits.
Once the bill was in place, Pelosi was saying, people would come to value and appreciate its contents. She was mocked for this relentlessly for years. But everything that’s happening this winter shows she was right all along.
GENERAL DISCUSSION OF THE BILL
The Kaiser Family Foundation offers an excellent side-by-side comparison of the ACA and Trumpcare at this link, as well as a Health Reform resource page with links to relevant KFF articles and analyses.
Chait, Jonathan: Paul Ryan Won’t Admit His Plan Is Obamacare, Only Less of It
Obamacare created two vehicles to cover people who couldn’t get insurance. It expanded Medicaid to cover the poorest of the uninsured, and those who made more money received tax credits they could use to buy insurance on new state-based exchanges.
Trumpcare cuts funding for Medicaid by $370 billion over a decade, and the cuts are heavily backloaded [see chart]
And it reduces funding for subsidies on the exchanges by $2,409 per person by 2020. To be sure, that is an aggregate figure. There are huge variations. . . . older, poorer customers in high-cost markets (like rural areas, especially) would get absolutely hammered. Abby Goodnough and Reed Abelson report on a few of them. In North Carolina, a 55-year-old would see her tax credit cut from $8,688 to $3,500. A 60-year-old would see his family’s tax credit reduced from $25,164 to $11,500.
Those cuts would make any decent insurance plan not remotely affordable.
Given the rhetoric Republicans have used over the past seven years to attack health reform, you might have expected them to do away with the whole structure of the Affordable Care Act — deregulate, de-subsidize and let the magic of the free market do its thing. This would have been devastating for the 20 million Americans who gained coverage thanks to the act, but at least it would have been ideologically consistent.
But Republican leaders weren’t willing to bite that bullet. What they came up with instead was a dog’s breakfast that conservatives are, with some justice, calling Obamacare 2.0. But a better designation would be Obamacare 0.5, because it’s a half-baked plan that accepts the logic and broad outline of the Affordable Care Act while catastrophically weakening key provisions. If enacted, the bill would almost surely lead to a death spiral of soaring premiums and collapsing coverage.
Rampell, Catherine: The Republican health-care plan isn’t about health care at all
Let’s abandon the pretense.
Republicans’ “health care” bill is not really about health care. It’s not about improving access to health insurance, or reducing premiums, or making sure you get to keep your doctor if you like your doctor. And it’s certainly not about preventing people from dying in the streets.
Instead, it’s about hundreds of billions of dollars in tax cuts — tax cuts that will quietly pave the way for more, and far larger, tax cuts.
[Rampell cites several analyses to support her points, including a series of estimates from the Joint Committee on Taxation.] Based on what the Joint Committee has scored so far — and it has not analyzed every revenue loser in the bill — these tax cuts come to about $600 billion.
Waldman, Paul: The new Republican health-care plan is awe-inspiringly awful
Waldman discusses the following points:
>The Republican bill undoes the ACA’s expansion of Medicaid.
>It replaces the ACA’s insurance subsidies with a[n insufficient] tax credit.
>It does away with the individual mandate, in a way that could lead the individual market to collapse.
>The Medicare trust fund will be drained sooner.
>It allows insurance companies to charge older people a lot more.
>It gives a huge tax cut to the wealthy.
>Planned Parenthood is barred from receiving Medicaid reimbursements for a year.
INITIAL CBO REPORT COMMENTARY
The initial CBO analysis may be found here.
A Summary of Facts from the Analysis
1. 14 million people will lose health insurance in 2018—that’s next year—mostly in the individual marketplace.
2. 24 million people will lose health insurance by 2026. This completely erases the gains made to date by the ACA. (Some reports say more will lose coverage.)
3. Premiums will rise by an average 15 to 20% by 2026, and will rise most dramatically for the elderly.
For example, under the ACA, a 64-year-old male, making $26,500 a year, now pays $1,700 per year for health insurance, or about 6% of his income.
Under Trumpcare, he will pay $14,600, or 55% of his yearly income. Most likely, he will not be able to afford this, and will then be left uninsured.
4. $880 billion will be cut from Medicaid funding. 73% of Medicaid beneficiaries are children, seniors, and people with disabilities.
5. $592 billion of the $883 billion in tax cuts will go to the very wealthiest individuals and corporation.
A Selection of Articles
Barry-Jester, Anna Maria, and Casselman, Ben (at 538): The GOP Health Plan Would Drop Coverage To Pre-Obamacare Levels, The CBO Says
Not only would the absolute number of uninsured people increase, the share of the population without coverage would be higher than it was before the Affordable Care Act passed in 2010; nearly 1-in-5 people under age 65 would not have health insurance by 2026, according to CBO estimates . . . .
It was already clear from the GOP bill that poorer, older and more rural people would receive less help buying insurance, while wealthier, younger people would receive more. The CBO drew the same conclusions and reported that those differences would likely shift who gets coverage. For example, in 2026, 21-year-olds would likely pay less for coverage under the Republican plan because premiums would be cheaper, even if they received fewer subsidies. But a 64-year-old who earned $26,500 per year would have to pay an estimated $14,600 under the GOP plan — compared with $1,700 under the current law. . . .
The [$337 billion] reduction in federal spending [over a decade] would come mostly from reduced spending on Medicaid ($880 billion) and from the elimination of health insurance subsidies ($673 billion). In other words, the Republican plan would cost less precisely because it would cover fewer people, many of them low-income families that qualify for Medicaid coverage under the ACA. (Both the spending and the coverage effects of those changes would be partly offset by the new health insurance tax credits, which would cost $361 billion through 2026.) Meanwhile, the drop in revenue would be driven primarily by the elimination of taxes imposed by the ACA — taxes that fell mostly on high-income households. So the Republican bill would pay for cutting taxes on the wealthy by reducing health care spending for low-income households.
Blake, Aaron: This may be the most brutal number in the CBO report
According to the CBO, 64-year olds making $26,500 per year would see their premiums increase by an estimated 750 percent by 2026. While they are on track to pay $1,700 under the current law, the CBO projects the American Health Care Act would force them to pay $14,600. Even if you grant that inflation will allow them to make slightly more money by 2026, that’s still about half of their income going to health care.
Krugman, Paul: Trumpcare vs. Obamacare: Apocalypse Foretold
The Congressional Budget Office report on Trumpcare is out, and it’s devastating: 14 million people losing insurance in the first year, 24 million over time, with premiums soaring for older, lower-income Americans — in many cases, the very people who went strongly for President Trump. The C.B.O. thinks it would reduce the deficit, but only marginally, around $30 billion a year in a $19 trillion economy.
The plan, the CBO concludes, would take more than $1 trillion away from programs targeting poor and middle-class families, to fund an $883 billion tax cut targeted at the wealthy. It is upward income redistribution of a truly massive scale.
“No legislation enacted in recent decades cut low-income programs this much — or even comes close,” Robert Greenstein, the founder and president of the Center on Budget and Policy Priorities and Washington’s leading advocate for poor and low-income Americans, says.
Pollack, Harold: Will “repeal and replace” implode?
I have been studying and practicing health policy for more than twenty years. I have never seen a less-professional, more shambolic legislative process than the one Republicans are now pursuing. . . .
So as of now, Republicans have created a political and policy fiasco. . . . Republicans failed to put in the work at the interface of politics and policy required to responsibly turn our $3.4 trillion medical political economy. Democrats crafted ACA over many months and years. The process involved repeated CBO scoring, analysis inside and outside government by many of America’s most respected health policy experts who knew this was hard, and really wanted to get things right. Democrats did the hard political and policy work in 2006, 2007, and 2008 that presaged the ACA, long before anyone expected Barack Obama to be President, Democratic Party interest groups and policy experts had gotten together, hashed out their differences, and coalesced around what would eventually become ACA. . . . The Senate bill that became ACA included more than 150 Republican amendments, too.
IMPACT ON MEDICAID
Peckham, Carol: A Black Hole for the Poor — Medicaid Under the GOP Bill
The new GOP American Health Care Act (AHCA) should be called “Well, Anyway, It’s Not Obamacare.” Right from the start all the random shreds of Republican ideas began with: anything but the ACA. Their Bill had to be its negation. An antonym. A void. And they have achieved it. The AHCA is a black hole into which they are kicking any hope for achieving universal care. The Bill is a travesty on many fronts, which we will address going forward. This article, however, focuses on Medicaid, where the foot of the GOP Bill falls most heavily.
IMPACT ON HEALTH CARE FOR WOMEN
Carol Peckham writes, in GOP Pushing Women Over the Cliff (Again),
Repealing the Affordable Care Act will hurt women far more than it will men. Women have lower incomes and greater health care needs and expenses than men have.
- About a quarter of all women live below the poverty line and 16% are single mothers.
- Before the ACA, 20% of all women reported they postponed or went without preventive care because of cost.
- ·About 45% of all pregnancies in the United States were unintended
The goal of the ACA was to insure everyone — either through Medicaid or through private health insurance using tax credits and subsidies for those with low income. 4 in 10 of those pregnancies ended in abortion.
Also see Scholar Strategy Network’s Fact Sheet, What Repeal and Replace Means for Women’s Health.
IMPACT ON DEDUCTIBLES
Drew Altman, at the Kaiser Family Foundation, in Why deductibles would rise under the GOP health care plan, explains:
Health care is complicated, as the president has discovered. But here is one thing that is not so complicated: if people have modest means and limited tax credits, and coverage is expensive, they will mostly buy health plans with lower premiums — and high deductibles.
This is what is likely to happen under the GOP health care bill, the American Health Care Act. Only people who need more health care will stretch for more generous coverage. If that happens, those health plans will draw too many sick people, causing insurance companies to stop offering them for fear of losing money. That would leave mostly the low-premium, high-deductible plans.
IMPACT ON STATES THAT VOTED FOR TRUMP
Contrera, Jessica: In a place of need, an unhealthy contradiction
Heartburn is just the latest problem for Clyde, a patient Keisha sees every three months. Like so many in this corner of Appalachia, he used to have a highly paid job at a coal mine. Company insurance covered all of his medical needs. Then he lost the job . . .
Because of the ACA, Clyde’s visit is covered by Medicaid. Before the law, most West Virginians without children or disabilities could not qualify for Medicaid, no matter how poor they were. . . .
As for the other problems in his life, he has put his hopes in Trump, who came to West Virginia saying he would bring back coal and put miners back to work. When Trump mentioned repealing Obamacare, Clyde wasn’t sure what that might mean for his Medicaid. But if he had a job that provided health insurance, he reasoned, he wouldn’t need Medicaid anyway, so he voted for Trump, along with 74 percent of McDowell County.
Goodnough, Abby, and Martin, Jonathan: G.O.P.’s Health Care Tightrope Winds Through the Blue-Collar Midwest
Pegge Sines, 62, of rural Edgerton, Ohio, did not vote for president, but her husband, a longtime factory worker who died of lung cancer in December, was an ardent Trump supporter. They had subsidized private insurance through the health care law that covered virtually all his treatment, she said.
Ms. Sines now pays $222 a month for her insurance from the Affordable Care Act marketplace, with a tax credit of $712 covering the rest. That $8,544 annual subsidy is more than twice the $4,000 annual tax credit she would get under the Republican plan.
Rubin, Jennifer: Many states that voted for Trump would suffer under Trumpcare
. . . using the Kaiser Family Foundation figures, the Los Angeles Times found: “Most affected by the Republican health plan would be parts of Alaska, Arizona, Nebraska, Tennessee and Oklahoma, where Obamacare insurance subsidies have been crucial in making high-priced insurance affordable. All five states went for Trump. Also hit hard would be parts of key swing states that backed Trump, including Pennsylvania, North Carolina and Michigan.” If someone set out to devise a plan to hit Trump voters the hardest it would be difficult to come up with something to match House Republicans’ plan.
ADDITIONAL ARTICLES ON VARIOUS ASPECTS OF TRUMPCARE (HOUSE VERSION)
Quealy, Kevin, and Sanger-Katz, Margot: The 9 Big Revisions Republicans Made to Their Health Care Bill, and Why They Made Them
Jost, Timothy: Essential Health Benefits: What Could Their Elimination Mean? (The title is misleading, as this article covers a wide range of proposals that were considered during the final days.)
Jost, Timothy: What’s In The Manager’s Amendment To AHCA?
Sanger-Katz, Margot: Late G.O.P. Proposal Could Mean Plans That Cover Aromatherapy but Not Chemotherapy
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