Republican healthcare plan is not what the doctor ordered

For the better part of a decade, we have heard a much wailing and gnashing of teeth coming from the rightwing end of the political spectrum over the horrible, no good, very bad, totally socialist, job-killing, death paneling legislation known as the Affordable Care Act.

Obamacare as Republicans would derisively call it was to be the end of America.

From the moment it was first proposed straight through to the present, every setback or bump in the road was bemoaned by the GOP as an unmitigated disaster, as evidenced, in their opinion, by the law’s abject failure.

{mosads}There is just one problem. Even as they gear up to destroy it, the ACA is actually working. The rate of uninsured Americans since its passage has fallen by half, from a high of 18 percent in 2013, to only 8.6 percent today, which is the first time in history the percentage of citizens without health insurance has fallen below 9 percent.

This year’s open enrollment period alone saw another 2.3 million people added to the rolls through state and federal marketplaces, bringing that total to 13.8 million Americans enrolled in a healthcare plan since to roll out of Obamacare (even Democrats started to like that name when it became clear the plan was working).

This doesn’t include the millions of people who receive coverage as a result of the Medicaid expansion, despite the nineteen mostly GOP-controlled states which rejected billions of aid dollars for their most vulnerable citizens.

And the ACA was beginning to bend the cost curve as those who drafted the legislation intended. The CBO, along with a bevy of other independent analysts, have estimated that the downstream effects of the ACA will save taxpayers upwards of $2.4 trillion dollars off the long-term debt if it’s maintained.

And for the first time, the ACA enjoys the support of a majority of Americans, now that millions are looking at the very real possibility of losing the security its protections offered. For years, the GOP delighted in pointing to the law’s unpopularity among voters as reason enough to repeal it.

What they ignored was the opposition to the ACA took two basic forms: Those to the right of the plan who falsely equated it to a socialist government takeover and wished to see it destroyed; and equal numbers to the left who opposed it because they viewed it as a giveaway to private insurance and healthcare providers instead of the true universal, single-payer system.

The GOP’s miscalculation was assuming that everyone who hated the ACA did so for the same reasons they did and would therefore support repeal and a return to the same capriciously cruel system that preceded it. It’s an assumption that’s coming back to bite them in town halls, protests, and phone campaigns across the country.

But now, after seven years of hollow promises, the republicans in Congress, led by House Speaker Paul Ryan (R-Wis), have finally turned in their long-overdue assignment with the reveal of a 66 page draft proposal they’re calling the American Health Care Act, or the AHCA. As any parent of a child with ADD knows, sticking an extra ‘H’ in the middle of something usually makes everything worse, and the AHCA is no exception.

As recently as January, Trump once again promised that whatever plan the GOP coughed up would cover everyone, with better benefits, for less money, much to the laughter of anyone familiar with healthcare and cries of ixna the etterba and eapercha from Congressional republicans who knew damned well they wouldn’t be able to deliver on that promise.

And indeed they couldn’t. Accurate assessments of the plans impact are difficult to come by, due in no small part to the congressional GOP trying to push the bill through before a CBO review on its fiscal impacts can be completed as House rules require.

However, early projections estimate between ten and as many as eighteen million people would lose their coverage in the first year alone. Estimates say that will result in ten to twenty thousand preventable American deaths annually, or to put that in perspective, three to six times as many people as we lost on 9/11 every single year. And the only known fiscal impact is to give a half trillion-dollar tax break to the nation’s wealthiest earners.

From a premium standpoint, the plan is completely untenable. It preserves the ACA’s pre-existing condition protections, but eliminates the much-maligned individual mandate. The problem with that is the unpopular mandate is the mechanism which makes the other popular components like the pre-ex, no lifetime caps, etc possible. Without the impetus of a tax penalty cajoling younger, healthier people to sign up, the insurance risk pool will naturally begin to skew towards those individuals with complex, expensive conditions, driving premiums, copays, and deductibles through the roof and very likely triggering a premium “death spiral” as the few remaining healthy people are driven from their plans due to cost increases, leaving only the sick and old. This feedback loop has devastated insurance plans and even entire companies in the past.

Moreover, the GOP plan specifically targets the older pre-Medicare population by shifting age-rating caps from 3:1 to 5:1, meaning Americans much over forty could see an immediate premium jump of 66 percent as soon as next year, even without any changes to their health situation.

For these reasons and many others, opposition to the AHCA has been swift and powerful. 

The American Hospital Association, American Medical Association, and AARP have already come out strongly against the legislation. GOP senators and representatives are signaling resistance in unexpected numbers, with many publicly saying the party needs to slow down the process and others already vowing to vote against it. The ironically named House Freedom Caucus has denounced the proposal for, as best I can tell, not being needlessly cruel enough.

Old conservative causes like selling insurance across state lines (which is a complete red herring, by the way) are notably absent from the plan, which led Fox News to question why it hadn’t been included and prompted Donald Trump to reassure everyone that state line restrictions would be addressed in “phase 2 & 3 of healthcare rollout.” Apparently he’s tackling healthcare the same way Marvel is building their cinematic universe.

The AHCA is crap, is what I’m saying. It is being attacked from both sides, and the people pushing it have the distinct look of kids who partied all semester and just turned in an essay they wrote the hour before the last day of class started.

So what can the GOP do to pull themselves out of the fire? Well, I have suggestions:

• First, cajole non-complying states to accept the federal Medicaid expansion. Their citizens are paying taxes for everyone else to receive those benefits while getting nothing in return. It would immediately extend coverage to an additional four to five million people currently locked out of the system and bring billions into state economies while cutting state level spending.
• Second, set up state insurance marketplaces and get off the federal exchange. This will give states more control over the companies, benefits, and premiums being offered to their residents.
• Third, push their state insurance departments to aggressively challenge insurance carriers on their rates each year. States that have done so generally have lower premiums and copays than those which do not.
• Forth, make participation in state individual healthcare marketplaces mandatory for any carrier that wants to sell group insurance in the state. This will bring an end to carriers pulling out of state exchanges just because this one small component of their revenue stream isn’t profitable enough.
• Fifth, reinstate risk-corridors. When the ACA was first drafted, insurance carriers pointed out, correctly, that rolling back pre-existing condition exclusions and lifetime benefit maximums would expose them to risks that their actuarial teams would have no way to model for a complete lack of historical data. The answer the Obama administration came up with to this reasonable objection was something called “risk-corridors,” which was just a way of saying if a company’s losses due to these new regulations surpassed a certain threshold, the government would reimburse them for the difference. But risk-corridors were opposed by the GOP (and many democrats) for driving up spending. So instead, they were cut from the final legislation and, sure enough, many companies suffered significant losses in the opening years of the ACA as many millions of people with health conditions went on plan and suddenly tried to catch up with many years of overdue medical treatments. Premiums, copays, and deductibles jumped accordingly, which they wouldn’t have had to if risk-corridors had been left in place.
• Sixth, use the negotiating power of Medicare/Medicaid, by far the largest insured block in the country, to start driving down the costs of prescription medications. For years, the GOP has resisted allowing the government directly negotiating drug prices with pharmaceutical companies for their enrollees as all other insurance carriers do. This is an enormous waste and frankly, anti-free market, as it thumbs the scales in favor of drug company profits and against open competition.

If you’re thinking these suggestions share a common theme, you’re right. For the GOP to deliver on Trump’s promise to provide better, cheaper healthcare to more people, all they must do is fix the parts of the ACA they deliberately sabotaged over the last seven years and get the hell out of the way. Let it run for a few years the way it was actually intended to and see what happens.

If it still needs work, fix it then. In the meantime, they can call it whatever they want. Trumpcare, Republicare, I don’t care.

Just stop killing my friends.

Patrick Tomlinson is an author, and regular contributor to the Hill on state, local and national politics. For the last 15 years he has been a health insurance agent focusing on health options for senior citizens. Follow him on Twitter @stealthygeek.

The views expressed by contributors are their own and are not the views of The Hill.