Trump prescribes poison for a failing system

March 17, 2017

Dennis Kosuth, a nurse in the Chicago Public Schools and member of the Chicago Teachers Union, and's Alan Maass explain the nightmare that Donald Trump and the Republicans want to inflict on us as a replacement for Obamacare--and the wider context of a health care system that was already in crisis and a "reform" law that didn't deliver reform.

A 7-YEAR-OLD student is brought into the office of the school nurse, his jacket covered in blood. The flow from his nose has slowed, and he amazingly keeps up a brave face despite the obvious pain of such an injury. The nurse calls his mother and explains the unfortunate collision with some playground equipment, and she arrives to retrieve him.

The bridge of the student's nose is slightly deformed by the accident, and the nurse assumes the parent will bring the child to a doctor. Problem: While his mother has insurance, for which she pays a high premium, there is a $3,000 deductible--so the cost of any care would all come out of her pocket.

Clearly ashamed, the parent explains that she can't afford an emergency room visit and will simply take the child home.

Probably every health care worker in this country has witnessed a similar situation, likely worse than this. Statistics from the Kaiser Family Foundation bear out the anecdotes in sterile numbers: Four out of ten insured adults report difficulty affording their deductible, and one out of three have trouble paying the premiums. Three in ten report problems paying medical bills, and of that group, seven in ten say they cut back on spending on food, clothing or other basic items to compensate.

Donald Trump with House Speaker Paul Ryan
Donald Trump and his new best friend Paul Ryan

Putting off or postponing care is common, including for people with insurance, because of high deductibles and co-pays. According to Kaiser, one in three people report they or a family member skipped dental care in the past 12 months because of high costs, one in four skipped a recommended test or treatment, and one in five cut pills in half or skipped doses of medication.

Access to health care has always been unequal and tragedy-filled in the U.S., the only major industrial country in the world without a universal health care system. But things got worse, not better, in a number of ways under Barack Obama's Affordable Care Act (ACA), commonly known as Obamacare.

The ACA included some important reforms, such as forcing insurance companies to provide coverage to people with so-called "pre-existing conditions"--that is, recognizing that they were sick and needed health care--and it expanded the government Medicaid program for the poor to cover more people.

But by far the biggest beneficiary of the law that was supposed to fix a system in crisis was the health care industry. At the center of the law was the requirement that everyone not covered by employer-provided insurance or a government program buy coverage from a private insurer or pay a substantial tax penalty.

The problem, of course, is that being insured doesn't equal having access to health care. Millions of people have been forced to purchase coverage that is barely affordable with high monthly premiums--that becomes unaffordable when people get sick and need it, because of high deductibles and other out-of-pocket costs. Plus, the ACA accelerated the same trends--co-pays and co-premiums, deductibles, more restrictions in coverage--in employer-provided insurance.

THUS, DONALD Trump and the Republicans were able to exploit very real frustrations and anger among people disappointed by Obamacare to win votes last November.

But their drive to repeal Obamacare will push the American health care system out of the smoking frying pan and into the fire.

Essentially, Trump and his new best friend, House Speaker Paul Ryan, want to gut as many of the few positive elements of the ACA as possible; restructure other provisions in ways that will make the health care system even more chaotic and irrational; and generally use the "repeal and (probably) replace" process to accelerate the transfer of wealth from the rest of us to the very richest people in U.S. society.

They may not get away with it. The unveiling of Trumpcare has been such a mess that the administration and Republican leaders in Congress are facing opposition from both directions inside their own party, not to mention the complaints of Democrats who insist that Obama's ACA was working fine.

On the right, the cuts proposed in the confusingly named Trump-Ryan American Health Care Act (AHCA) aren't aggressive enough for some Republicans, who criticized the proposal as "Obamacare Lite."

A National Review writer went so far as to claim that any bill maintaining the ACA regulation barring insurance companies for excluding people with pre-existing conditions--one provision that Republicans generally haven't had the guts to oppose--was a betrayal of the promise to repeal Obamacare.

On the other side of the GOP--it's hard to call this bunch of reactionaries "moderate," though they are less fanatical than the Tea Partiers--there is fear that passing the Trump-Ryan plan will make the Republicans responsible in the eyes of ordinary people, including voters in 2018 and 2020, for the looming catastrophe to come, including the number of uninsured Americans skyrocketing to pre-ACA levels.

Arkansas Sen. Tom Cotton, who is far from a liberal admirer of Obamacare, nevertheless warned fellow Republicans: "Do not walk the plank and vote for a bill that cannot pass the Senate and then have to face the consequences of that vote."

This week, Ryan admitted that the legislation would have to be changed in the face of criticism from fellow Republicans, but it will be no easier than before to come up with something that isn't a mess.

NEVERTHELESS, TRUMP and the Republicans won't stop pushing, and they have a lot of different ways to do damage.

The main elements of "repeal and (probably) replace" will come through the budget legislation that is now being furiously debated in the House. Because "reconciliation bills" that deal with taxes and spending can't be filibustered, the GOP can gut significant portions of the ACA with just a 50-percent-plus one majority, rather than the 60 percent of votes needed to stop a filibuster in the Senate.

The sections of the ACA that regulate insurance companies, such as extending coverage for children up to age 26 and guaranteeing coverage despite pre-existing conditions, can only be altered through regular legislation, so the Republicans are unlikely to go after these provisions, even if they wanted to, because they would need 60 votes in the Senate to stop a filibuster.

But Trump can do a lot of damage by administrative action, without the trouble of even going to Congress.

According to reports, the administration is planning to order a regulatory change to reverse the requirement that policies sold through the ACA-mandated "exchanges" must cover the cost of contraceptives.

In the same way, Trump could also substantially alter the ACA's cost-sharing subsidy system for out-of-pocket costs, which lowers the maximums for lower-income enrollees in an exchange policy through a direct federal government payment to insurers.

The main focus right now is on the Trump-Ryan AHCA, which would reverse, repeal or restructure the ACA's expansion of Medicaid, the mandate on individuals to purchase insurance, and subsidies for buying coverage for people below a certain income level.

Analysts are still discovering the ticking time bombs in various aspects of the legislation, but it's obvious that Trump and Co. want to honor their promise to repeal Obamacare--which had a certain amount of support among working people frustrated with the ACA's failures--by screwing over working people and extracting as much of their money as possible to deliver into the pockets of the rich.

AMONG THE many provisions of the AHCA, it's worth looking in detail at how the Republicans want to counter Obamacare's expansion of the Medicaid program. Though there was some money in it for medical corporations, this benefited poor people most of all--so it's naturally at the top of the Republican hit list, as it has been since Obamacare was passed into law in 2010.

In 2012, the U.S. Supreme Court ruled on a lawsuit filed by Republican governors and officeholders in 26 states who wanted to get Obamacare scrapped altogether. A majority of justices voted to uphold the parts of the ACA that benefit the health care industry the most.

But by a 7-2 vote, the Court ruled that the federal government couldn't threaten states with losing existing Medicaid funding if they refused to go along the expansion. Effectively, this was a green light for states to opt out--only 31 states and the District of Columbia are signed on.

The ACA's expansion of Medicaid already suffered from the fact that it was sending millions of people into a system that had been damaged by decades of cutbacks and restrictions imposed by the state governments that administer the program (usually with the approval of the federal government that oversees it).

But the Supreme Court's opt-out ruling was a huge blow to the poor in the 19 states that denied them access to Medicaid.

One consequence is that there are 2.5 million adults in these states who fall into a coverage gap. They are not poor enough to qualify for Medicaid under the pre-ACA rules, but they fall below the lower income limit to get financial assistance for insurance bought through the ACA "exchanges," as they must because of the individual mandate.

The Republicans' proposed AHCA is a declaration of war on Medicaid programs of every state.

The legislation would cap funding for Medicaid without regard to increases in health care costs or more people enrolling in the program. Funds to cover the more than 11 million people newly eligible for Medicaid under the ACA would be phased out. The Congressional Budget Office (CBO) estimates that 14 million fewer people would be covered under Medicaid than expected by 2026. That's two-thirds of the CBO's projection of an additional 21 million people without insurance in the U.S.

Perhaps the most grotesque fact about the AHCA is that the Republicans explicitly plan to transfer the Medicaid spending reductions into the pockets of the already obscenely rich.

The House version of the legislation would reduce Medicaid spending by $880 billion over a 10-year period from 2016 to 2017, accounting for three-quarters of the $1.2 trillion in reduced spending by demolishing the ACA. But the lion's share of the "savings" would be transferred to the rich through tax credits or the repeal of ACA's new taxes to pay for provisions like expanding Medicaid.

For example, if Republicans succeed in eliminating two additional Medicare taxes created under the ACA--an additional Hospital Insurance tax on high earners and the Medicare tax on unearned income--households with an annual income of $1 million or more would get tax cuts of $49,370 a piece. The richest 0.1 percent of households, with incomes above $3.8 million, would get tax cuts of more than $195,000 on average.

THERE ARE many more disasters lurking in the AHCA that will need to be untangled and exposed in the weeks to come.

Republicans are determined to remove the tax penalty that adults not covered by employer insurance or a government program must pay--the individual mandate, un-ironically known as the Individual Shared Responsibility Payment. The also plan to get rid of the employer mandate requiring companies with 50 or more employees to provide affordable insurance.

This might benefit younger, healthier adults willing to run the risk of going without insurance, but older adults will be penalized by a provision that allows insurers to charge them five times more for policies. This adds insult and injury to the lingering injustice of the ACA: that a health care "reform" law allowed the insurance thieves to charger older customers three times more than younger ones.

The Republicans also want to get rid of another important part of the ACA--subsidies that helped people with lower incomes buy insurance or pay for out-of-pocket costs. Instead, the AHCA would replace the subsidies, paid directly by the government to insurance companies, with age- and income-based tax credits. The CBO report analyzing the Trump-Ryan bill concludes that this will result in far less money being used to make insurance more affordable, and that lower-income people will suffer disproportionately.

"We're going to have insurance for everybody," Trump said back in January, promising that he and the Republicans would give people "great health care. It will be in a much simplified form. Much less expensive and much better."

Not quite, according to the CBO report that ends with an estimate which sobered even some Republicans: The number of people without insurance would increase by 24 million compared to under the ACA.

Some of the opposition among Republicans is no doubt due to the fear of being held responsible for pushing the number of uninsured above where it was before Obamacare.

Plus, the health care industry itself is concerned that the AHCA could be a debilitating shock to the system. The massive Medicaid cuts and loss of insurance coverage would have a huge impact on corporations organized around income from government health programs. Both the American Hospital Association and American Medical Association have opposed the Trump-Ryan bill.

But if the Republicans can get away with this mess, a few people will be dancing. According to the Tax Policy Center, "Forty percent of the benefits of [tax cuts associated with Obamacare repeal] would go to the highest-income 1 percent--those making more than $772,000 in 2022."

IN THE next days and weeks, the spotlight will be on the Republican reverse-Robin-Hoods and their plot to rob the poor of their health care to pad the pockets of the rich.

And rightly so. But as the outcry grows, we shouldn't forget that the Obama administration set the stage for this new extortion scheme by pushing through a health care "reform" law that failed to deliver reform.

After his landslide election in 2008, Obama and the Democrats had a mandate to take real action to restructure the failing health care system--and they had control of the White House and both houses of Congress needed to do it.

But the new administration declared from the start that it wouldn't even consider a single-payer system that could guarantee access and control spiraling costs by cutting out the insurance company parasites. Instead, Democrats made sure that the ACA was tailored to keep the health care giants at the table. When push came to shove, Obama was prepared to bargain away even the inadequate "public option" of maintaining one alternative to private insurance in order to appease the industry.

The health care industry conceded on measures that were bound to pass even a Republican-controlled Congress--like barring insurance companies from using pre-exiting conditions as an excuse to reject people--in return for legislation that guaranteed them millions of new customers through the individual mandate.

Ever since, the corporations have been lobbying to keep the ACA's regulations as toothless as possible, while using their position of advantage to offer ever-more-expensive insurance policies that provide less coverage at greater cost.

If the Republicans are in a position to whip up support for repealing Obamacare, it's because the Democrats championed a health care law that mainly made the corporations richer--and far too many ordinary people poorer after paying inflated health care bills.

Meanwhile, the crisis of the U.S. health care system is getting worse. In 2012, average life expectancy in the U.S. stopped rising after two decades of steady increases, and it has now started falling--the opposite direction of almost every other industrialized country on the planet.

A 2015 study by Princeton economists Angus Deaton and Anne Case defies common sense--it found that the death rate for white men and women aged 45 to 54 with less than a college education increased dramatically between 1999 and 2013, largely due to legal and illegal drug addiction, alcohol abuse and suicide.

An increase in the mortality rate for any large demographic group in an advanced country was virtually unheard of in recent decades, with the exception of Russian men after the collapse of the ex-USSR.

It's painfully clear that the existing system doesn't work for the majority of people. Yet Trump, Ryan and the Republicans want to make matters even worse.

They have a long way to go before they can get away with their grand theft health care scheme. Opposition has grown steadily since Trump's election and especially since he took office, and that will make it hard for the Republicans to succeed in their main aims.

But even if the worst is avoided in the latest health care wars in Washington, it won't address the underlying sickness of the health care system--which will only be cured by a movement that can win a single-payer system that guarantees health care for everyone as a human right.

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