Yesterday, the Trump administration unveiled plans to allow insurers to skim healthy customers out of the insurance pool by offering skimpy plans that last for up to three years. The legally dubious maneuver is the crowning touch on the administration’s persistent efforts to undermine the Affordable Care Act. Conservative intellectuals are justifiably ecstatic. “Wednesday’s rule came to be because dedicated people within the Trump administration worked hard to push federal policy in a libertarian direction,” exults Cato Institute scholar and onetime author of the “Anti-Universal Coverage Club Manifesto” Michael Cannon. Indeed, Trump’s attacks on Obamacare, taken together as a sum, provide a fair picture of the American right’s unique, social Darwinist philosophy of health-care policy.
Many people are either too poor or too sick to afford access to medical care. In every democracy in the world save the United States, a broad social consensus accepts the need to subsidize care for those people. This includes the conservative parties in those countries. Among right-of-center parties in the developed world, only the Republicans are so committed to anti-government dogma as to oppose measures to subsidize medical care for those who can’t afford it themselves.
But whenever Democrats have attempted to expand access to health care, Republican leaders have generally declined to present themselves as principled opponents of universal health care. Instead, they have promised they could accomplish the same goal in a better, cheaper fashion, without any of the painful trade-offs in the existing Democratic-authored proposals. No such plan ever emerged, in part because Obamacare was the most market-friendly way to accomplish the bare minimum objectives of any humanitarian health-care reform. The only space to Obamacare’s right involved punishing the poor and sick with medical and financial deprivation.
It is now clear that, on its own terms, Obamacare’s policy design worked. When the new marketplaces opened, insurers initially set premiums far lower than the Congressional Budget Office expected, and — as it turned out — lower than the market would bear. After correcting their initial under-pricing, insurers settled their premiums at a stable level that was both affordable to most consumers (especially in states that tried to make the markets work, as opposed to sabotaging them) and profitable for them.
Amazingly, the exchanges have survived despite eight years of legal attacks and administrative sabotage by both Republican state-level government and now the federal government under Trump. Republicans have eliminated outreach advertising for the exchanges, refused to issue required payments for insurers who accept disproportionately sick customers, and are now trying to lure healthy customers out of the exchanges, driving up costs for those who remain. The Republican line maintains that all these blatant attempts to kill the law are somehow the fault of the law’s designers. “Democrats want to blame the GOP for increases that are baked into the health law’s faulty design,” insists a pious Wall Street Journal editorial.
This is demonstrably false. A new study by Matthew Fiedler of the Brookings Institution shows that insurers in the exchanges have made a healthy 10 percent profit this year, and if the Trump administration had taken no additional steps to sabotage the exchanges, premiums would be coming down by an average of 4.3 percent next year.
A poll by Axios finds that, by a 20-point margin, Americans would rather keep Obamacare or do more than repeal it or do less. Republican politicians, caught between the unpopular extremism of their ideological vanguard in Washington and the moderate demands of the electorate, are retreating to evasions. In a New York Times story about Democrats focusing on health care, a Republican spokesperson gamely retorts, “A contrast between single-payer health care and our ideas — a more patient-centered approach — is a debate we fully welcome.” If you don’t know what “patient-centered” means, don’t worry. It has no meaning at all. Which is the point. The entire purpose of the phrase is to obscure the party’s health-care agenda.
Trump’s most recent step is to allow insurers to sell those skimpy plans with little coverage — excluding customers with expensive medical needs, who would be left in exchanges without healthy customers to help share the costs. This would provide some immediate cost-benefit to healthy customers, who would be free from cross-subsidizing the less fortunate. Of course, if they happen to suffer unexpected medical misfortune themselves, they will be out of luck.
The new Trumpcare plans will be cheap for people who are healthy enough to qualify. But they don’t cover much. If you find you’re having a baby, or need a weekend stay at a hospital, or even something as exotic as prescription drugs, you’re out of luck. The Journal editorial page insists this will all be fine, because “not everyone needs all benefits,” and also, “[t]he HHS rule also stipulates that issuers must prominently display a notice that the coverage isn’t compliant with the Affordable Care Act. Everyone will know what they’re buying.” Right, because everybody in America is already aware of what the essential benefits of Obamacare contain, and thus what their absence implies. Anyway, insurers are definitely going to make sure you’re aware of all the shortfalls and gaps in the product they’re selling you.
What is striking about the Trump-era Republican health agenda is the lack of policy ambition. Having spent years insisting they had an army of wonks who could design a better alternative to the Obamacare “train wreck,” the Republican plan of attack has dissolved into a rearguard sabotage campaign with no pretense of doing anything to help the poor and sick afford medical care. Health care remains a policy ground with which conservative-movement dogma cannot grapple.