HEALTH CARE/Joan Retsinas

Nostalgia for a Make-Believe Past: Return to Dreadful Future

The Republican debaters wax nostalgic for a once-upon-a-time America, wonderful in myopic retrospect. A 1950s America with few immigrants – not the recent swarms from all corners of the Globe. One where states ruled supreme, without the bungling of an aggressive Uncle Sam. Schools, healthcare, welfare, public safety – states carved out their own approaches, free to carve out key populations for beneficence or neglect.

In that Edenic past, we didn’t have all those protests – from women, from gays, from blacks. Everybody stayed in their slots – women at home, gays in the closet, and blacks at minimally-paid jobs in businesses and homes owned by white people. Abortions were back-allley, or done quietly in the offices of expensive physicians. Today most Americans reject that cruel Nirvana.

But not the Republican Presidential candidates.

Jeb Bush has issued his salvo to Obamacare. He, like his compatriots on the debate stages, has vowed to repeal the Affordable Care Act. Here is what he would substitute:

a) Rejection of comprehensive coverage for the new goal: catastrophic coverage. No coverage for routine visits, for preventive care, for outpatient procedures, for diagnostic tests. High deductibles, high co-payments. This will protect against catastrophic expenses. Of course, the line between high and catastrophic expenses is in the eye of the beholder. For some enrollees, $5,000 out-of-pocket would be catastrophic; for others, OK.

We are not used to catastrophic coverage. We now assume that our insurer, even with deductibles and co-payments, will pick up most of the tab for most of our expenses. The goal of the Affordable Care Act was comprehensive coverage, with none of the “gotcha” loopholes insurers wielded to limit expenses.

Ironically, it was senators, many Republican, who pushed through, in a nonpartisan world “mandates” like breast reconstruction after mastectomies (1988, spearheaded by Sen. Alphonse D’Amato, R-NY), coverage of pregnancy, minimum stays post childbirth. We have just made “mental health services” part of the normal package. Farewell to that, under this plan. Also under the possible axe: mammograms, colonoscopies, Pap smears, EKGs, well-baby visits, inoculations, drugs. Budget-cutters know how to cut.

b) Return to pre-existing condition exclusions.

Remember those loopholes where insurers refused to cover treatment for whatever ailed you at the time you enrolled? Insurers profited from those loopholes. They must be cheering this plan.

c) No more individual mandate; no more employer mandate.

In this Eden, nobody will force anybody to buy insurance. No penalties for not enrolling. Employers will offer tax incentives to nudge people to buy plans on the private market – if they want to. The question to ponder: how high will our census of the uninsured soar? How high will hospitals’ losses soar? Fifteen years ago candidates trumpeted their plans to insure the uninsured. Now that the Affordable Care Act has helped to lower that census, candidates are going to raise it.

d) Medicaid caps

Twenty states refused to expand Medicaid under the Affordable Care Act. Those states can rejoice: The Bush plan will return Medicaid to states’ control – and let them impose caps, which will translate into caps on services, caps on payments, and/or caps on eligibility. Another question to ponder: how destitute will the poor need to be to get care? How limited will that care be? And, if history is any guide, how widely will states diverge in accepting responsibility for the poor? Some of the Republicans touting state power hail from states that have spent the least on their poorest citizens. Ironically, one of our successful programs, Food Stamps, was designed as a national program, under the tenure of President Richard Nixon (who tried, but failed, to refashion welfare as well). Another irony: it was Jeb Bush’s father who, as President, proposed a national approach, using the federal employee insurance system as the backbones of a plan to expand coverage.

In the coming weeks, more Republican candidates will roll out their plans. Expect more nostalgia for this make-believe past.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, December 1, 2015

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