//  5/2/17  //  Commentary

Yesterday, I began a series of posts on healthcare reform by explaining how the interrelated nature of many provisions in the Affordable Care Act (ACA, or Obamacare) increases the complexity of healthcare reform efforts.  Today, I continue this theme by comparing key provisions of the actual GOP repeal bill, the American Health Care Act (AHCA, or Trumpcare), to the bill the President seems to believe is under consideration. 

This post takes as its inspiration the President’s Sunday interview on Face the Nation, in which John Dickerson did what few reporters have done thus far – press the President for specifics on his health care plan and how it would work.  Importantly, in that interview (which you should watch or read), the President contradicts himself on a number of points within the span of a few minutes.  So it’s difficult to say precisely what he believes Trumpcare does and doesn’t do.  But it’s safe to say that no version of his beliefs matches reality, and that there are at least two large areas of distinction between real Trumpcare – the version currently on the table in the House – and Unicorn Trumpcare, which would magically lower premiums, cover everyone, and provide coverage for all services.

The first area of distinction is one I covered in yesterday’s post: the role of pre-existing conditions.  On Face the Nation, Trump stated that “Preexisting conditions are in the bill.  And I mandate it.”  Now, in one sense he’s right – Trumpcare requires insurers to offer plans to individuals with pre-existing conditions.  The problem is that, unlike under the rules of Obamacare, Trumpcare permits them to offer such plans on wildly discriminatory terms, charging individuals with pre-existing conditions tens of thousands of dollars more in premiums each year.  It hardly “protects” people with pre-existing conditions to offer them entirely unaffordable insurance.  Realistically, many if not most of these people won’t be able to obtain health insurance if Real Trumpcare passes.  This is a key difference from Obamacare and from Unicorn Trumpcare.

Now, at certain points in his interview the President seemed to suggest that he appreciates this problem.  He did so by referring to high-risk pools, which provide coverage for people who are otherwise uninsurable due to their current or previous illnesses.  For instance, he stated – albeit unclearly – that “pools are going to take care of the preexisting.”  In theory, this is entirely possible.  In practice, however, high-risk pools have been total failures. 

Most importantly, an enormous amount of money is required to adequately fund an insurance pool made up entirely of sick people.  HHS recently estimated that the cost to cover the nearly 18 million Americans who were uninsured due to preexisting conditions in 2010 would have totaled $194 billion, while Trumpcare appropriates just $15 billion – over nine years – to help this population.  If the administration is willing to spend hundreds of billions of dollars more to shore up these pools, that would be one thing.  However, it does not appear that they are willing to do so.  So unlike Unicorn Trumpcare, Real Trumpcare won’t have workable high-risk pools and many people with pre-existing conditions therefore will lose access to affordable (or any) health insurance.

A second area of distinction concerns the affordability and coverage offered by plans.  In contrast to Obamacare, which provides subsidies tied to income for individuals to purchase insurance, Trumpcare provides subsidies based on the recipient’s age.  Combined with a provision that enables insurers to charge older people five times as much as they charge younger people (Obamacare permits only a 3:1 ratio), many have expressed concern that Trumpcare would be unaffordable for many in the 55-64 age group, before Medicare eligibility kicks in at age 65.  Just to take one example, the CBO estimated that, for a 64-year old making $26,500 a year, the annual out-of-pocket premium under the ACA would be $1,700.  Under Trumpcare?  It would be $14,600, more than 8.5 times higher.  That’s a distinction with a difference.

On Face the Nation, John Dickerson sought to remind the President of this problem, specifically the much higher premiums Trumpcare may create for the near-senior population.  Trump’s response?  Only that this problem has been “[t]otally fixed.”  When pressed on how it had been fixed, Trump could say only that “[t]his bill is much different than it was a little while ago.”  He offered no specifics and could not explain how the new version of the bill would do anything to help this population.  That’s because no changes have been made to help them.

This is the ugly reality about Trumpcare that many Republicans seem unwilling to admit.  “[W]e’re going to drive down premiums,” says the President. “The premiums are too high,” he adds.  And, in fairness to Trump, the original CBO score of the AHCA does suggest that premiums will go down in the long term – by about 10%. 

That said, we’re going to drive them down only by pricing older, sicker people out of the marketplace.  It’s true: if your insurance pool is made up only of young, healthy individuals, premiums will decline relative to a marketplace that includes older individuals, or individuals with pre-existing conditions.  But a vision of insurance that magically lowers all premiums, covers everyone, and provides coverage for all services?  It’s a unicorn.  Totally imaginary.

Why is it so hard for Republicans to come up with a market-driven health care system under which, as the President put it, “competition is going to drive down the premiums”?  Well, it’s because we already have such a system – and it’s called Obamacare. 

Recall that Obamacare started life as a conservative policy.  Indeed, a very similar system was successfully implemented by then-Governor Mitt Romney – individual mandate and all – in the state of Massachusetts in 2006.  Simply, President Obama passed a Republican health insurance bill – and now the Republicans are struggling to find something more free-market that doesn’t simultaneously roll back coverage on tens of millions of people.

In tomorrow’s post, I consider the implications of the President’s ignorance of this and other bills for his duty to take care that the laws be faithfully executed.

The Affordable Care Act Does Not Have An Inseverability Clause

11/5/20  //  In-Depth Analysis

Contrary to challengers’ claim, Congress nowhere directed the Supreme Court to strike down the entire ACA if the individual mandate is invalidated. Congress knows how to write an inseverability directive, and didn’t do it here. That, combined with Congress’s clear actions leaving the ACA intact and the settled, strong presumption in favor of severability, make this an easy case for a Court that is proud of its textualism.

Abbe R. Gluck

Yale Law School

Sovereignty In A Public Health Crisis

5/4/20  //  Commentary

Don Herzog explains why sovereignty talk is useless to resolving public health issues -- and basically everything else too.

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Why HHS Can't Keep Cutting Corners As It Attempts To Undo Non-Discrimination Protections

3/30/20  //  In-Depth Analysis

HHS has recently tried to essentially repeal an important rule that prevents the Department from discriminating across its many programs. But, as contributor Harper Jean Tobin explains, its rule making is both substantively and procedurally illegal.

Harper Jean Tobin

National Center for Transgender Equality