Wednesday’s report from the Congressional Budget Office ought to erase any lingering doubt about how Republicans are trying to change American health care.
If they get their way, they will protect the strong at the expense of the weak ― rewarding the rich and the healthy in ways that punish the poor and the sick.
Republicans have tried mightily to deny this, and accused their critics of dishonesty. President Donald Trump, Vice President Mike Pence, House Speaker Paul Ryan (R-Wis.) ― they and their allies have insisted over and over again that their proposals would improve access to health care and protect people with pre-existing medical conditions.
But it’s the Republicans who are lying about what their plan to repeal Obamacare would do.
They were lying back in March, when they introduced the initial version of the legislation ― a bill GOP leaders had to pull at the last minute because it didn’t have enough votes to pass. And they have been lying since early May, after they revised that proposal and rushed to vote on it before the CBO, Washington’s official scorekeeper, had time to evaluate it formally.
Now the budget office analysts have done their work. And if they are right, then the revised legislation would punish economically and medically vulnerable Americans more than the earlier version would have ― leaving many millions without insurance and unraveling the market for insurance for people with pre-existing medical conditions.
To be clear, CBO’s overall assessment didn’t change much, since the basic framework of the bill hasn’t changed much either.
Older people would still face higher premiums, as insurers would gain more leeway to vary prices based on age. Lower-income people buying private insurance on their own would still lose financial assistance, as a new formula for tax credits would steer money away from them. And the very poor would still lose access to Medicaid, as states would lose funding they otherwise would have gotten from the federal government.
Some people would feel better off as a result of these changes ― young people in relatively good health would get access to cheaper coverage, for example, while more affluent people who get little or no financial assistance from the government today would start to get more. Wealthy people would get extra money in their pockets, since the GOP legislation would undo the taxes that finance the Affordable Care Act’s coverage expansion.
But the net effect would be 23 million fewer people with health insurance ― many of whom, as a result, would face financial or physical hardship because they could no longer afford medical care. That’s nearly identical to the 24 million that the CBO estimated would lose coverage from the bill’s previous version.
The one big change Congress made to that bill is a set of amendments that would allow states to waive some of the Affordable Care Act’s most important regulations, including rules that prohibit insurance companies from charging higher premiums to people with pre-existing medical conditions.
Republican leaders have insisted that these amendments, so essential to winning over holdout lawmakers in the House, wouldn’t actually make much difference to consumers.
Even in states that sought the waivers, GOP leaders promised, insurers could engage in “medical underwriting” ― that is, varying premiums based on health status ― only for people who allowed their coverage to lapse for more than two months. And that was bound to be a small number of people, Republicans said.
On Wednesday, the Congressional Budget Office indicated just how wrong that argument is.
For one thing, coverage lapses of more than two months would be pretty common under the GOP bill, because lower-income consumers who struggle to pay premiums would be getting less financial assistance than they do today. More important, the CBO pointed out, allowing insurance companies to vary premiums based on medical conditions even in some cases would inevitably create a bifurcated insurance market.
Insurers would end up setting up two sets of plans ― one with medical underwriting and one without. Healthy people would flock to the underwriting plans, since they’d be eligible for cheaper coverage there. The older plans would be left with a relatively sicker population, forcing them to raise premiums for everybody still enrolled in them and thereby encouraging more healthy people to leave ― until, eventually, those plans had shrunk to small groups of people with big medical problems.
Premiums in these plans would be much more expensive, and in many cases downright unaffordable, making access to them for people who had maintained continuous coverage essentially meaningless. As a result, the CBO concluded, “People who are less healthy ... would ultimately be unable to purchase comprehensive non-group health insurance at premiums comparable to those under current law, if they could purchase it at all.”
The finding echoes an analysis that Matthew Fiedler, a former Obama administration economist who now works at The Brookings Institution, published shortly before the House bill passed. And on Wednesday, in an email to HuffPost, Fiedler noted that the people the GOP bill would marginalize are those that, in theory, an insurance system should prioritize. “Those markets would no longer fulfill one of their fundamental purposes, which is ensuring that people can get health care when they need it,” he said.
Of course, insurance markets under the Republican scheme would serve other purposes ― like limiting the size and scope of government, offering cheap coverage to younger and healthier people, and allowing wealthier Americans to keep some money they now pay to the federal government in the form of taxes.
Republicans may think that pursuing those goals ultimately does society more good than guaranteeing health insurance for the people who need it most. Such thinking would be consistent with the way they have tried to govern more generally, with their constant efforts to strip down programs for the poor and middle class while showering the wealthy with tax cuts.
But when talking about health care over the past few years and especially in the past few months, Republicans have pretended they have different priorities ― a deception the CBO exposed quite clearly on Wednesday.