We suppose that those inclined to give President Trump the benefit of the doubt on health care reform could say his recent executive pronouncements are just a ploy to get either Democrats to negotiate or Congress to act – or both. Allowing “skinny” interstate insurance policies with little coverage and cutting premium subsidies to insurers are meant to get the attention of Congress, not to be implemented, some could say.
Trump might get away with that more nuanced interpretation of his attitude toward the Affordable Care Act except for the fact that when Congress was poised to act, he was anything but subtle. He pushed first for a “repeal” bill that would have cost more than 20 million people their health coverage; then he lobbied on behalf of a “replace” bill to give greatly reduced grants to states, many of which would promptly drop the requirement to cover pre-existing conditions in order to avoid raising state taxes (states, unlike the federal government, must balance their budgets each year).
Both bills failed in the Senate, but only narrowly. A group of senators from both parties has worked out a two-year extension plan until Congress can craft comprehensive reform, but Trump has sent mixed signals, in one tweet repeating his contention that continuing the subsidies to insurers for lower rates they are required to charge, even for high-cost patients, is a “bailout.”
So a less charitable reading by many is that Trump is out to sabotage Obamacare if he can’t get Congress – even one controlled by Republicans -- to do the deed for him. His charge and those of many ACA opponents that it is “failing” seems a self-fulfilling prophecy: Destabilize any regulated market by changing the rules and the funding, and there’s bound to be an exit by most participants. The main financial beneficiaries of repeal would be the very wealthy, who can afford private insurance but who pay a higher, proportional tax amounting collectively to billions of dollars to underwrite Obamacare.
Republicans in Congress actually fired the first shot in the destabilization wars in 2014 when they found a loophole in the law that allowed them to withhold billions in insurer payments for so-called premium “risk corridors” without actually repealing the law. Three years later, some insurers are out of business or have left the exchanges, in part because of that kind of congressional undermining of the law.
The latest announced changes by Trump won’t affect this year’s signups on the exchanges starting Nov. 1. But the White House has narrowed the window to six weeks, done little publicity, and ordered the servers to go down for maintenance every Sunday – often the only day some people have to spend time online.
Some insurers like Blue Cross/Blue Shield of Arizona had hefty premium increases last year and are actually planning to lower premiums this year – theirs are the only plans being offered in Coconino County. The subsidies to signees in the form of tax credits remain, as do penalties for those going bare: $695 or 2.5 percent of income, whichever is greater. But the White House has sent mixed signals to the IRS on just how firmly it expects the penalties to be collected.
The bipartisan, two-year patch proposed in the Senate is a promising sign that lawmakers, if not the White House, recognize the importance of stabilizing the private insurance market. Polls show the public is solidly behind retaining the two bedrock principles of Obamacare: coverage regardless of pre-existing conditions, and subsidies based on income to make plans affordable (or expanded Medicaid for the very poor). To help insurers stay solvent and the government pay for that combination requires either much higher general taxes (as in countries like Canada with universal, single-payer coverage) or mandatory participation in the insurance pool by healthy, young adults. Republicans say such an arrangement amounts to “socialized” medicine, but they have yet to come up with a workable alternative that does not undermine both principles. Further, were they to defund Obamacare, much of the expansion in Arizona and elsewhere of Medicaid would contract, putting more unfunded care of sicker, poor people on the backs of rural hospitals like Flagstaff Medical Center.
At this point, we can only urge those in Congress to do the right thing by the majority of their constituents and stabilize Obamacare, not sabotage it, as the White House appears to be doing. Locally, we urge healthy young adults to sign up on the Exchanges if they are not insured through their employer – as we have reported, local insurance brokers like Ed Gussio are knowledgable and committed to making insurance work, no matter your income or state of health. Obamacare is not without flaws, but it and its principles are only failing in a political sense, and that is no way to improve the health of a nation.