There is one solid, coherent argument for the Senate health-care bill: If you believe the government redistributes too much money from the medically and financially fortunate to the unfortunate, then Trumpcare is a huge step forward. Its large regressive tax cuts and even larger cuts to low-income health-care subsidies would rebalance the tax-and-transfer system in a way that’s more fair, from a certain moral perspective.
But since that moral perspective is shared by very few people, Republicans have long ago internalized the need to find different public rationales. In the health-care case, what they have come up with is a simple, blunt-force denial that their plan to reduce health-care spending is anything of the sort. Fanning out on the media. Republican officials have spread word that nobody would lose any benefits at all. “We would not have individuals lose coverage,” says Health and Human Services Director Tom Price. “No one loses coverage,” echoes Republican senator Pat Toomey. “These are not cuts to Medicaid,” insists Kellyanne Conway.
House Republicans employed a similar strategy to pass their version of the AHCA.
Even for those of us inured to the effects of right-wing propaganda, it is bizarre to watch a party attempt to carry out a major welfare-state rollback while fervently insisting the welfare state will not be rolled back a single inch.
The task of giving an intellectual sheen to this facially absurd message has fallen upon Republican health-care adviser Avik Roy, who has sold the Senate bill in an enthusiastic media blitz. (I asked Roy this morning if he help the Senate leadership write its bill; he has not yet replied.) The Senate health-care bill scales back the subsidy for tax credits used for insurance under Obamacare. Currently, tax credits are enough to buy an insurance plan that covers 70 percent of your expected medical expenses. The Republican plan would cover just 58 percent of expenses. The difference comes out of customers’ pockets in the form of higher deductibles, which would rise from $3,500 a year on average to $6,300 a year.
In fact, rather than argue for higher deductibles, Republicans have spent the last several years insisting deductibles are already too high. The excessively high deductibles on the exchanges have constituted the GOP’s most popular talking point. (To take one example out of jillions: GOP senator Johnny Isakson: “Most of those 20 million got bronze policies with a great big deductible and not much insurance.”)
The thing about this old talking point is that, while it’s exaggerated — most exchange enrollees, especially the ones with the lowest incomes, have low deductibles — it’s not entirely false. As you go higher up the income ladder, the subsidy gets lower and lower, and both deductibles and premiums get higher. After exploiting these weak points for every ounce of advantage, the Republican plan would make it dramatically worse.
Indeed, the insurance a person could buy under the Senate bill would make regular medical care unaffordable for millions of people, even if they technically had “insurance.” A person earning $18,000 a year, who currently pays an annual deductible of $255, would pay $6,000 in deductibles. The millions of people who voted for Republicans on the promise of getting lower deductibles will be very surprised to learn that higher deductibles are the Republican party vision.
Right-wingers do have a vision of a system with high-deductible insurance. They like it because they believe people would make shrewd decisions about what medical care to buy and what to skip, bringing down costs. Honest conservatives (like Ross Douthat) admit that, to make a system like this work, Republicans would need to give low-income people generously-funded medical-savings accounts, from which they could draw to pay their costs. The Senate bill doesn’t do that. It just sticks poor people with medical bills they can’t possibly cover.
The second defense of the Senate bill is even more sweeping. Throwing people off Medicaid will not harm them, argues Roy, because it is “a program that researchers have shown has health outcomes no better than being uninsured.” Here Roy is repeating a claim he has made repeatedly over the years. The basis for this claim is one study of Medicaid recipients in Oregon. The study found that people enrolled in the program enjoyed measurably better financial security as well as measurably better mental-health outcomes. The study was unable to detect better physical health outcomes. Some analysts argue this failure was simply because its design could not pick up on health effects.
But you don’t need to wade into a debate over the technical merits of a single study to have a point of view on this question. As Benjamin Sommers, Atul Gawande, and Katherine Baicker point out in a new article in the New England Journal of Medicine, there are lots of studies about the effects of Medicaid. The research points overwhelmingly toward the conclusion that people benefit from having health insurance. “The body of evidence summarized here indicates that coverage expansions significantly increase patients’ access to care and use of preventive care, primary care, chronic-illness treatment, medications, and surgery,” they conclude. “These increases appear to produce significant, multifaceted, and nuanced benefits to health.”
Roy’s tactic of cherry-picking one (disputed) facet of a single study in order to justify withholding access to medical care from the poor and sick is exactly the kind of rhetorical contortion necessary to justify a plan lacking any widespread public support.
Update: Roy emails back: “As a matter of policy, I don’t discuss with the press my conversations with policymakers.” So, if you’re curious whether he helped write the plan he has been touting in a number of op-eds and interviews, Roy isn’t saying, but “yes” seems like a fairly safe assumption.