I heard on the radio on Monday that you are OK with voting on some version of Trumpcare before it gets a score from the Congressional Budget Office, because you don’t believe the conclusions that office reached on the original version of the American Health Care Act.
Earlier that day I’d called your office to ask whether you would vote on the matter without a CBO score, and your staffer wasn’t aware of your position, so it was good to get that question answered eventually.
On the same phone call, I asked about your position on the current version of the bill, and the staffer said you hadn’t decided yet, because you were evaluating the bill in its entirety.
That’s commendable, but it makes an odd pairing with your stance on the CBO process.
The structure of the most recent version of Trumpcare is pretty simple. It repeals some of the taxes that were implemented as part of the Affordable Care Act, with the reductions falling primarily to higher-income households. All else being equal, that’s a reasonable thing to do—I’m not a believer in taxation for the sake of taxation.
On the other side of the ledger, it results in some millions fewer people having health insurance than if the ACA is continued. We can obviously argue over how many millions (more on that below), but presumably you would agree that if millions of people are getting health insurance through Medicaid, and hundreds of billions of dollars are removed from Medicaid, a lot fewer people will have insurance.
It also preserves Essential Health Benefits (EHBs) in name while allowing them to be gutted in practice through the state waiver process, which is very permissive (the standards for a state to get a waiver are almost impossible to fail to meet). This would mean that insurers would again (as before the ACA) be allowed to offer policies
On the surface, it prevents women from being charged more than men, but if a state gets a waiver from EHBs relating to gynecological care, the result can be that in effect women are charged more than men (or get less value for the same premium).
As I’ve described in earlier communications, even for people like myself who will still have health insurance after the repeal of the ACA, the bill under discussion will have bad effects on the health care available to us as rural hospitals and providers are weakened with the loss of revenue from patients whose care is currently funded by Medicaid.
Most troublingly, in light of your earlier statements of support for guaranteed coverage of pre-existing conditions, the waiver process allows such coverage to be avoided. The proposed work-around is that a state has to have a high-risk pool of its own or participate in a federal high-risk pool, but there are two problems with that.
First, the country has experience with high-risk pools from before the ACA, and they work very poorly. The coverage they provided was still very expensive for people with pre-existing conditions, pricing many people out of coverage. In fact, that was a major reason why the ACA was adopted.
Second, there’s no clear commitment to funding the high-risk pools adequately, which is the key to making them possibly work. Covering people with pre-existing conditions costs money, and the priority with the various versions of Trumpcare seems to be on enabling a large tax cut, which may simply be at odds with guaranteeing coverage of existing conditions.
So there’s not actually all that much to consider. A large tax cut, vs. millions of people losing health coverage. Are you trying to figure out exactly how many people will lose coverage?
Let’s say that only two (2) people gained coverage because of the Affordable Care Act. If you set that against a tax cut of $900 billion, then it’s an easy decision. There are much cheaper ways of insuring any two people.
But if it’s 24 million people? A significant number of those will die 5, 10, or 20 years earlier than otherwise, due to lack of insurance. A significant number of them will go through bankruptcy brought on by medical expenses, due to lack of insurance, setting their families back by years and putting larger financial burdens on the communities around them.
Is that worth the tax cut that would come with Trumpcare?
And if 24 million people is too many to justify the tax cut, then what is your number? If it were only 10 million, would you be OK with that? If women were treated fairly but states could still in effect get out of covering pre-existing conditions, would that be an acceptable tradeoff?
Which brings me back to the CBO score.
The outlines of Trumpcare’s effects are pretty simple. Scoring a bill is actually much harder. You have to make a series of reasonable assumptions about how people’s behavior will change in response to the legislative changes being considered.
- If the individual mandate is weakened or removed, how many people will opt to cease buying coverage?
- How many will drop out because subsidies for purchase on the individual market are reduced?
- As healthier people pull out of the pool, how much will premiums go up for those who are left?
- As those premiums go up, how many more people will “opt” (or be forced by finances) to drop coverage?
- If Medicaid is block-granted to the states, how much financing will states put in as medical costs per capita rise?
- As the block grant falls short, what steps will states take to limit Medicaid eligibility, and how many people will that remove from Medicaid coverage?
Do you think CBO’s number is wrong? I would respect that statement a lot more if you would back that up by specifying and justifying the assumptions you think they should be using instead of the ones they are using.
Karl Seeley
Earlier communications with Faso's office on the subject:
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