Wayne O'Leary

Welcome to Conservative Health Reform

After endless invocations of “freedom” and “choice” calculated to excite their indoctrinated base, and disingenuous double talk about “universal access” aimed at disarming the public at large, Republicans are ready at last to dip their toes into the turbulent waters of health reform. The wonder is it took so long, since the proposals emerging from their meeting of the conservative minds mostly amount to a repackaging of tired right-wing proposals dating back a decade or more.

The point men for the GOP’s leap of faith are (first and foremost) House Speaker Paul Ryan, followed by Vice President Mike Pence, Secretary of Health and Human Services Tom Price, and, in a supporting role, President Donald Trump himself. Republican members of the Senate are less in evidence. Their formal spokesman, Majority Leader Mitch McConnell, has always cynically viewed calls for ending the Affordable Care Act (ACA) as more a partisan electioneering device than anything else; he’s content to leave the details to Ryan, who views ACA repeal as a test of ideological purity.

The president, his promise to kill the ACA “on Day One” already well past its due date, has begun to back and fill, admitting to the nation’s governors in late February regarding health-care policy: “I have to tell you, it’s an unbelievably complex subject. Nobody [least of all the Donald] knew that health care could be so complicated.” He, too, is happy to turn things over to the House Republicans’ resident big thinker, who’s been working this terrain his entire career, and get back to tweeting and holding rallies.

So what have Ryan and company come up with to make everyone’s medical life better? On March 7, we found out. Essentially, House Republicans are endorsing the reform framework they initially put together last June, then sat on through the presidential season for fear of calling attention to its more controversial features and jeopardizing their ticket. They needn’t have worried; the ticket won, and the White House, according to HHS Secretary Price, is now “all in” on the pending scheme.

To begin with, Ryancare (or Trumpcare, if you prefer) would repeal the ACA’s individual mandate and make job-based coverage optional once more for large employers. In the process, it would end the expandable, income-based federal subsidies Obamacare provides to offset premium costs incurred by lower- and middle-income participants in the exchange program. Instead, Republicans would encourage the use of so-called health savings accounts (HSAs) and supplement those personal savings with far less generous fixed federal tax credits unrelated to income. Health-care consumers would thereby be afforded the “freedom” to save whatever they could to purchase insurance on the open market, while hoping their meagre tax credits helped cover rising premiums.

Things would be substantially worse for those dependent on Medicaid. Republicans visualize changing this Great Society health entitlement for the poor into a welfare program with a limited set budget distributed to the states on a per-capita block-grant basis. Echoing welfare, a work requirement might be added at the state level, and premiums or limited-benefits packages could legally be part of the mix, as well as enrollment caps. The ACA’s Medicaid expansion would cease to exist as such, the additional federal money it generated cut drastically and redirected by the states for other purposes, such as subsidizing privatized plans for enrollees.

Vice President Pence’s Scrooge-like fingerprints are all over the proposed Medicaid revisions. In 2015, as governor of Indiana, he blackmailed the Obama administration into foolishly granting him waivers from a number of standard federal requirements, his price of accepting Medicaid expansion under the ACA. Indiana recipients must, unlike those in other states, pay monthly premiums and contribute selective co-payments. In addition, Indiana now divides its Medicaid population into multiple categories, the better to monitor use of the program and discourage participation.

If Medicare beneficiaries think their entitlement is different and safe from the Ryan axe, they need to think again. Despite President Trump’s casual assurances, the GOP is coming after them, too. Wisconsin’s fiscal grim reaper remains dedicated to transforming Lyndon Johnson’s crown jewel from a government-run form of social insurance into a market-based system euphemistically called “premium support.” In place of guaranteed care, seniors would be issued government vouchers of indeterminate value and forced (or freed) to shop in the private sector for whatever affordable health plan they could find to fit their needs.

Which brings us to Mr. Trump. Besides leading the Obamacare repeal chorus, his primary contribution to the threatened conservative disruption of American health care consists of advocating for a pet GOP policy panacea that’s become party orthodoxy, the sale of health insurance across state lines. Facilitating nationwide marketing of insurance would, according to the Donald, become the basis for radically lowered health-care costs in a deregulated post-ACA world, resulting in “great plans.” Unfortunately, as a 2015 New York Times analysis revealed, it falls well within the realm of Republican faith-based health reform.

The magic cure-all would theoretically reduce premium prices by setting off a frenzied race to the bottom among insurers, encouraging them to concentrate operations in states with the fewest insurance regulations and offer low-cost, one-size-fits-all national plans. Aside from the obvious danger to consumers inherent in reduced government protections and oversight, this dream of a free-market nirvana fails to factor in financial and network barriers, such as establishing contracts with sufficient numbers of cooperating doctors and hospitals. Significantly, neither the insurers themselves, nor their lobby, America’s Health Insurance Plans (AHIP), have shown much enthusiasm for this impractical excursion into conservative ideology.

Nevertheless, the radical right is undeterred. In Paul Ryan’s words, with Republican health reform, “You get the freedom to do what you want and buy what you need.” The free market über alles! But perhaps Donald Trump’s working-class supporters, many of whom would suffer the economic consequences of the proposed descent into anarchy, should get the final word.

Last December, the Kaiser Foundation held health-policy focus groups featuring Rust Belt Trump partisans enrolled in either the ACA exchanges or Medicaid. While still trusting the president’s intentions, they rejected outright almost everything he and his party want to implement, including HSAs, flat tax credits, and high-deductible catastrophic plans. Compared to guaranteed health-care security, Paul Ryan’s freedom fetish registered hardly at all.

Wayne O’Leary is a writer in Orono, Maine, specializing in political economy. He holds a doctorate in American history and is the author of two prizewinning books.

From The Progressive Populist, April 15, 2017


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