The speaker of the House says coverage numbers are just numbers on a spreadsheet.
And President Donald Trump’s budget director thinks the agency that exists to evaluate large pieces of legislation shouldn’t waste its time evaluating health care reform.
Those were some of the arguments flying around on television Sunday, as administration officials and Republican congressional leaders were defending the House Republican bill to repeal the Affordable Care Act.
The timing is critical. This is the week that the Congressional Budget Office will issue its official projection of how the proposal would affect the federal budget and insurance coverage. Independent analysts have already predicted that it would cause millions of people to lose health insurance and pretty much everybody in Washington assumes the CBO will reach a similar conclusion ― though nobody knows for sure.
If the Republican proposal were to cause significant insurance losses, it would run contrary to a promise Trump made over and over as a presidential candidate ― that “everybody’s got to be covered.” More important, it would also mean millions of Americans would lose affordable access to care they need, sometimes to survive.
On Sunday, administration officials and Republican leaders laid out the three arguments they plan to use in response. None hold up well to scrutiny.
Argument No. 1: The CBO isn’t reliable
Republicans have been making this argument loudly for a few days now: The CBO got it wrong when it predicted the effects of the Affordable Care Act, so there is no reason to take it as gospel now.
Here was Mick Mulvaney, budget director for the Trump administration, on ABC’s “This Week”:
If the CBO was right about Obamacare to begin with, there’d be 8 million more people on Obamacare today than there actually are. So I love the folks at the CBO, they work really hard, they do, but sometimes we ask them to do stuff they’re not capable of doing, and estimating the impact of a bill of this size probably isn’t the ― isn’t the best use of their time.
But the CBO got the basic gist of what happened right, even if it was off in the magnitude. In May 2013, the CBO predicted that the number of people without insurance would drop by about 45 percent. Data from Gallup suggests that, according to its baseline, it came down by about 36 percent. And there’s plenty of reason to think the number would be higher if, say, all states promoted enrollment with the enthusiasm states like California and Kentucky did.
The CBO’s biggest error on enrollment was about the exchanges ― that is, people buying through HealthCare.gov and state sites like Covered California. The CBO was way off there, as Mulvaney says. But partly that was because the CBO also expected more people would leave their employer plans, by choice or because their employers stopped offering them. Another factor, according to Edwin Park of the Center on Budget and Policy Priorities, could be that many people are staying in old, “grandmothered” plans ― which originally the law was not going to allow.
Note, too, that with fewer people getting coverage through the exchanges, the federal government is also spending less. And it looks increasingly like CBO projected premiums just about right.
No forecast is perfect. But the CBO’s are as good as anybody’s, if not better. If the agency ends up saying the same thing as so many other forecasters ― that the Republican plan would mean many millions lose insurance ― then it’s a safe bet the prediction is roughly correct.
Argument No. 2: The ACA is collapsing anyway
“They’re scoring Obamacare as it exists today, not tomorrow,” Mulvaney said. “Obamacare’s this close from completely collapsing. For example, I live in South Carolina, we are down to one provider in that state. There’s four or five states that I think are down to one provider. And the CBO is failing to take into consideration what happens to folks in South Carolina when there are no providers, which there may be as soon as next year.”
The newly reformed markets in some states are struggling right now. That is a fact. Insurers generally haven’t attracted young and healthy people in the numbers that they had hoped, so many are losing money ― and, in response, some are pulling out of markets altogether. The situation is worst in a handful of states, like Arizona and North Carolina, where large swaths of the population have only one carrier right now. As of today, some counties in Tennessee have none lined up for next year.
Shoring up those markets is both an important and not-that-difficult task for an administration and Congress interested in doing so. Some combination of regulatory tweaks and a little extra money would probably suffice. The House bill even has one such provision, a program to offer carriers “reinsurance,” tucked in amid all the other radical changes.
At the same time, plenty of states have successful, stable markets where consumers can still choose from a variety of plan choices, with prices comparable to or better than employer policies ― and that’s before accounting for the law’s tax credits.There are also signs that even the weaker markets are improving, now that insurers have raised prices to be more in line with their costs.
The forecasters don’t expect coverage losses simply because people getting subsidized plans will lose their insurance. They also expect a huge decline in Medicaid enrollment, because the Republican plan would roll back the Affordable Care Act’s expansion and then ― on top of that ― create a new funding system for the program that’s likely to cut its spending over time.
Argument No. 3: Coverage doesn’t matter because it’s all about care
Mulvaney said it doesn’t matter whether people have “a little plastic piece of paper that says they have an insurance policy.” On CBS’s “Face the Nation,” House Speaker Paul Ryan (R-Wis.) said he’s not going to worry about whether the Republican plan produces a “nice-looking spreadsheet” of coverage statistics. The issue, they and other Republicans say, is whether people have better access to care.
Nobody would dispute that last part. The ultimate goal of health care policy is to make sure people can go to a doctor, fill a prescription or get other forms of medical care when they need it ― and without experiencing severe financial distress. Similarly, a lot of people who have bought private coverage through the exchanges have policies they consider unaffordable, or even unusable, because the out-of-pocket expenses are so high. This is a failure of the law that even its supporters have said they want to remedy.
But for millions, out-of-pocket costs have come down, because their new insurance has smaller co-pays and deductibles, because it covers more services or because they had no coverage previously. (If you are uninsured, all medical care is an out-of-pocket expense.) Overall, access to care has improved while financial distress from medical bills has declined, according to research published in places such as the Journal of the American Medical Association.
If the Republican plan becomes law, the cumulative effect of its changes both to regulations and financial assistance will be that exposure to medical bills gets bigger, not smaller. On the whole, premiums might end up coming down, if the entire GOP agenda comes to pass, but then out-of-pocket costs would soar. Costs for the average enrollee would go up by $1,542 in 2018 and by $2,409 in 2020, according to calculations that Harvard economist David Cutler and a group of colleagues published in Vox last week.
That figure doesn’t even take into account all the people who would lose Medicaid coverage and end up uninsured. Republicans like to say the program doesn’t do any good, but it improves access and reduces financial distress, according to a huge amount of scholarship.
Averages always mask variation and some people, including some middle-income people, will be better off if the Republican plan becomes law. But overall the trend will be to shift federal assistance away from people who need it most in order to afford care. Without that assistance, getting care will become more difficult, not less.
“I firmly believe that nobody will be worse off financially in the process that we’re going through, understanding that they’ll have choices that they can select the kind of coverage that they want for themselves and for their family, not the government forces them to buy,” Tom Price, HHS secretary, said on NBC’s “Meet the Press.”
It’s a slightly different version of a promise he made earlier this week, that nobody would lose coverage at all. And not much easier to justify.
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