President-Elect Trump and the Republican-led Congress are talking about repealing the Affordable Care Act, and then letting it sort of sit around still being in effect until they come up with something to replace it. This means a vote to repeal will happen in a policy vacuum.
They’re not going to simultaneously repeal it and replace it like they promised during the general election, because it turns out that you need something to replace it *with* in order to do that, and all they have right now is a piece of paper on which Trump has scrawled, “this is going to be so great you guys it’s the best healthcare the greatest.”
Trump’s big ideas that he talked about during the election were: make healthcare premiums tax-deductible, eliminate the individual mandate, retain the ban on pre-existing condition clauses, retain keeping people on their parents’ insurance until age 26, convert Medicaid into a block-grant program, and remove barriers to selling health insurance across state lines.
Let’s talk about his ideas a little bit, ranked best to worst. (First off, a caveat: I work in healthcare as a frontline admin, and I read a lot because I’m interested in these issues, but I’m not an expert.)
Retain keeping people on their parents’ insurance until age 26:
This is good. (Oh god oh god I agree with Trump on something.)
Make healthcare premiums tax-deductible:
This is great for me and other people who pay taxes and have employers who provide good insurance, and kind of meaningless for the uninsured people who already don’t make enough money to pay taxes. It would help those small business owners and freelancers who have the cash liquidity to allow them to pay the premiums and then get paid back in a lump sum tax return. It would help the economy every April since people do tend to spend their tax rebates pretty quickly. It might make our deficit larger because of taking in fewer net taxes, I don’t know. I’m not against it, but as a proposed solution to a lack of coverage, it’s interesting as an example of Republicans (and Trump especially) not understanding what it’s like for people who live paycheck to paycheck.
Remove barriers to selling health insurance across state lines:
The theory is that insurers who can offer national plans regardless of where the patient lives will save money and reduce the price of insurance. One of the arguments against this is the “race to the bottom” one: insurers in states with a lot of tight regulations will get outbid by insurers in states with lax regulation, so effectively everybody in the country ends up under the laxest regulations. That’s not good, but I’m not sure that would actually happen – there’s no federal law (as far as I could find) preventing insurers from doing this, and there are some states that already allow out-of-state insurers but nonetheless have very few, so I presume insurers aren’t already doing it because it’s more hassle than it’s worth.
It’s a ton of work to set up the networks that would be needed in each location for this to work. I mean, my costs go way up if I try to see an out-of-network doctor. Just because somebody in (let’s say) New Hampshire has a really amazing insurance plan that’s cheap and includes every doctor in the state doesn’t mean that that plan would work for me, no matter how cheap it is, because I don’t want to travel to New Hampshire for care and that insurer may not have a good network of doctors set up in Tennessee.
I was able to find endorsements for this idea from Ted Cruz, Rand Paul, Marco Rubio, Rick Santorum, and Scott Walker, who all like to talk about states’ rights except for when they don’t care about states’ rights, like with this idea, which tramples all over states’ desire to regulate their own stuff.
Eliminate the individual mandate, and retain the ban on pre-existing condition clauses:
I’ve put these two ideas together even though Trump isn’t talking about them together, because the individual mandate (which I think a lot of people object to on individual-liberties grounds, including me) is what makes retaining the ban possible. The entire idea of insurance is to insure a population against adverse events. If you allow people to *enter* the insurance pool when they *have just had* an adverse event, there’s no particular incentive for young, generally healthy people (who don’t need a lot of care outside of emergencies and other adverse events) to maintain insurance coverage when they’re well. They can wait until they need it and buy it then, and because there’s no pre-existing condition clause, there’s nothing to prevent them from coming and going from the pool of insureds as it’s convenient for them. If the pool of insured people doesn’t include people who are generally healthy, then the cost of insurance inevitably goes up. So, I’m in the awkward position of defending the individual mandate, not because I like it, but because I can do math.
Convert Medicaid into a block-grant program:
Right now, the federal government requires states to cover certain groups and to provide certain benefits, and in return, it helps cover costs. Block grants would convert Medicaid into 50 programs (one per state) with the feds providing a pre-set amount of money to each one, and the states deciding how to run their own programs but also having to cover any costs over and above the grant. Trump is correct that block grants can be structured to save the federal government money – but in order for that to happen, either people have to lose coverage who currently have it, or states have to absorb the costs of those “savings.” Trump claims that money can be saved by “streamlining,” but creating 50 sets of administrators with 50 sets of rules which all gazillion insurers and hospitals have to now deal with is the opposite of streamlining. This is just a terrible idea from beginning to end.
So what’s going to happen?
Paul Ryan loves block grants, and Trump loves making other people pay for things that are his responsibility, so Medicaid might be screwed, unless Republican Governors talk them out of it. Probably we should all be calling our governors’ offices to express our opinions about this.
If the Republicans do some math, they’ll realize that the individual mandate is necessary unless we bring back pre-existing conditions clauses, which are very unpopular. Either they’ll retain the individual mandate, call it something else, and declare victory, or they’ll bow to the insurance companies and bring back pre-existing conditions clauses.
Mostly I expect them to fumble around with a few changes, but basically pass something that looks a lot like the ACA (which, let’s remember, started as Romneycare). They’ll rebrand it and swear up and down that it’s totally different.
The changes they do make will make insurers (/campaign donors) an absolute fuckton of money, and whether or not that makes things more expensive or less accessible to the general public won’t really factor into their decisions unless we hammer them on it as an electability issue. So we need to do that, because they’re about to turn a mediocre law into a terrible one.
[Note from the future: NYMHM grew out of these public posts from Joanne Merriam’s Facebook account. We retain them here in archives to provide a record going back to the beginning of Trump’s presidency.]