Thursday, December 1, 2016

The (Tom) Price of repeal and replace: Trump's health care policy takes shape

John Cassidy (New Yorker) warns that the sick and poor will be the first casualties of the policies promoted by Trump’s pick for HHS Secretary, Rep.Tom Price: The first victims of repealing Obamacare will be the sick and the poor. I suspect that soon enough thereafter, as Pogo might have said, we have met the victims and they is us. And, ironically, “us” includes the working-class white Trump voters - who Paul Krugman calls “Trump chumps” (How Many People Just Voted Themselves Out of Health Care?)

Here, from Cassidy, is the essence.

Under Price’s plan, reversing the post–2010 expansion of Medicaid alone would mean that about fifteen million people would lose their health-care coverage overnight. These people—members of families whose earnings are above the poverty line but less than forty thousand dollars a year—would once again be subjected to the mercies of private insurers. They would be eligible for tax credits to help them purchase private plans, but these credits would, in general, cover only a small portion of the monthly premiums.

Ryan’s plan is less draconian than Price’s in that it would allow states that expanded Medicaid to maintain it. But Ryan would still reduce the level of federal funding for these programs, which would mean higher costs for enrollees. And like all the Republican plans that have been proposed, Ryan’s would scrap the subsidies that currently enable many low-to-middle-income families to purchase private insurance plans in favor of smaller tax credits. Among those who stand to lose out from these types of changes are many working-class white voters who obtained health-care coverage in the past few years but who also voted for Trump. According to a back-of-the-envelope calculation by Paul Krugman, the New York Times columnist, there could be about five and a half million of them.

… it is hard to see exactly how [Trump] will be able to both follow Price’s lead and keep his pledge to people with preexisting conditions. Under Price’s plan, insurers would still be legally obliged to offer coverage to sick people, but they could charge much higher premiums to anybody who hadn’t maintained continuous coverage—a loophole that could potentially affect millions. Sick people who couldn’t afford coverage in the regular market would be forced to fall back on special plans for high-risk people, which the federal government would subsidize. But the billion dollars a year that Price is proposing to devote to this purpose would be entirely inadequate. Inevitably, many sick people would fall through the cracks and end up with no coverage.

This example illustrates a more general problem facing Trump and the Republicans. The health-care economy that emerged from the Affordable Care Act is a Rube Goldberg contraption with many interlocking parts: laws, taxes, subsidies, public mandates, and administrative directives, along with the expansion of existing features, particularly Medicaid. Some of these pieces may have appeared to be superfluous, but they were designed to work together and support each other. If someone comes along and fiddles with one of them, such as the subsidies or the individual mandate, it can affect the entire system.

Last week, I ran into a health-care economist who used to work for the Obama Administration. She was extremely upset about the election results and about the forthcoming assault on the Affordable Care Act, and she said the one solace she could take was a political one. She would now get to watch Trump and the Republicans try to achieve the impossible: repealing, or replacing, parts of Obamacare without depriving millions of Americans of coverage and igniting a firestorm. In picking Tom Price as his point man on health care, Trump has signalled that he is willing to embark on just such a course.

That will be the Price of health care under President Trump.

No comments:

Post a Comment