Republicans are about to return the country to adequate health insurance only for the wealthy and those employed by big business. Donald Trump should not let them.
The 2010 Affordable Care Act – Obamacare – was a breakthrough. It eliminated the lack of coverage for pre-existing conditions and the maddening “out of network” denials, and with premium assistance greatly reduced the possibility of financial stress and bankruptcy for too many individuals and families. Importantly, depending on a state’s decision, it allowed Medicaid coverage to be expanded from 100 percent of the poverty level to 133 percent (from $12,060 this year to $15,800 for an individual). Overall, hospitals are being paid for much more of what was previously uncompensated care, reducing the cost-shifting that added to everyone else’s premiums.
Republicans are planning to provide less premium payment assistance than the ACA delivers, especially for those 60 to 64, and to end the Medicaid expansion for new enrollees in 2020. Tax credits, more cumbersome than premium assistance, will be used. And rather than basic Medicaid being open-ended for the 50-50 federal-state combination, block grants based on population served and average costs would be instituted. States will very likely have to reduce the populations they serve or reduce coverage for some treatments and procedures. In fact, that is expected.
The Office of Management and Budget expects 24 million fewer individuals to have insurance by 2024, and that premiums will rise in the meantime.
Trump campaigned with claims that under his presidency insurance coverage will cover more people and be less expensive than what was occurring with the ACA. “Better, much better” is one of his favorite expressions tied to his promises, and he used it liberally in regards to health insurance.
By working with the more centrist members (on this issue there are some, perhaps many) of his party, and firmly standing up to those on the far right who want little or no federal involvement in providing insurance, Trump could deliver on that promise.
It is also one of the few promises he has a chance of delivering because a new health care plan can be initiated fully by the political process. Adding jobs? That is not nearly so clear cut, as corporations may have other ideas. Doubling the growth of the economy from last year’s 1.6 percent (Trump talked about being able to deliver 3 to 4 percent growth)? Even less clear cut.
Premium assistance and the expanded Medicaid should continue. At the same time, there should be incentives for states to come up with ways to reduce Medicaid expenses, and it may not be unreasonable to require able-bodied recipients to have some employment, however minor. Paying health care providers on the basis of results not procedures should be the future, and that should be emphasized.
But if insurance is not mandated, as it is under Obamacare, and the tax on unearned income paid by the wealthy is not continued, Republicans will have to come up with other sources of supplemental funding. Affordable premiums will never solely cover the cost of adequate insurance.
Trump has four years to create his legacy, but if he can draw on his promises and apply his bluster to create a health care insurance system that will continue to cover almost all Americans (or more), he will have earned an important checkmark in the positive column.