The Health Care Fiasco

Richard Rubin
Attorney Richard Rubin has taught public policy at USF, UC Berkeley and other institutions and is Chair of the California Commonwealth Club Board of Governors

With thousands showing up at California town halls to discuss the unravelling of the Affordable Health Care Act and other issues it’s a sign all is not so well in Trump Land.

Nothing trumps (pun intended) the agenda—not even Russian meddling and intelligence compromises — so much as the future of our healthcare and what will become of the efforts underway to do away with the much maligned Affordable Care Act or Obamacare as opponents prefer to call it.

In meetings throughout California and across the nation lawmakers in both parties are getting an ear-full on what amounts to a strategy that will put one of America’s most significant social reforms in the past century into what some believe could be a death spiral.

This is likely to have political consequences if lawmakers are misreading the voters’ message.

In the California House delegation a number of GOP incumbents are facing elections in 2018 which could hinge on their views regarding the ACA. These include Rep. Darrell Issa from Vista in San Diego County in his eighth term who scratched out a very narrow victory (1,621 votes) last November.

Others considered vulnerable are Ed Royce of Fullerton (Orange County), Jeff Denham from Turlock (Stanislaus County), and Steve Knight from Lancaster (Los Angeles County).

Geography is not the main issue—it is economics and the link between the cost of adequate health coverage—the biggest concern in later years—and declining incomes which has people up in arms.

The crowds are certainly not coming to cheer the loss of benefits to the elderly, the very ill, the disabled, minorities, and the financially neediest if the GOP proposal succeeds which centers on elimination of the individual mandate—a necessity for the government program to have enough funds to sustain itself in the future.

Without this mandate which imposes penalties on healthier, mostly younger people who can afford it, they might choose not to pay into the program. Similarly, it eliminates the employer mandate for many businesses.

Without it, the effect would be to drive up the prices of private insurance for those in greatest need who will lack the ability to pay for the inevitable rise in insurance premiums.

Under the current program, to offset the cost of premiums, deductibles, and co-payments the government gives tax credits (subsidies) to help lower wage earners. Under the GOP plan the loss of these subsidies for millions—which would be based on age rather than income—will result in increased costs ranging from $4,000 to $6,000 per family, making such coverage prohibitive or unaffordable.

Along with the big insurance and drug companies, the wealthiest among us will do just fine. According to the Tax Policy Center, those earning at least $3.7 million annually—the top 0.1% of U.S. households—stand to receive a tax cut “of about $197,000 in 2017, if the ACA is repealed.

Some observers have pointed out that giving huge tax breaks to the biggest corporations does not exactly square with President Trump’s promise to help the little guys to whom he largely owes his victory.

As it is the ACA places a relatively small 3.8% tax on the investment income of the richest families which affects merely about 2% of households or couples earning more than $250,000 a year.

According to the Congressional Budget office, repeal of the ACA would result in $1 trillion in lost revenues which would make it difficult if not impossible to create a program with comparable benefits.

It is argued that premiums could eventually come down—perhaps in eight years— based on the usual market forces. It is also equally possible that by then millions will be without health insurance who have been added to the rolls under the ACA.

It is estimated that 14 million would lose their health insurance upon enactment of the changes with 24 million likely to be deprived of basic insurance by 2026. These numbers are coming from the non-partisan CBO whose director happens to be a Republican appointee.

The GOP proposal, although apparently doomed in its current form, is an untested antidote for what in the minds of many is an improving health system.

The most objective observers acknowledge there were flaws in the roll-out, fewer have signed up than anticipated, in some states the choice of physicians has been narrowed, and—most importantly—an insufficient number of otherwise healthy individuals (mostly younger) have chosen not to sign up which can starve the program of the revenues it requires in order to fully flourish.

Another argument being put forth mainly by conservatives is that repeal will reduce the federal deficit in 10 years—a claim that not only cannot be substantiated at this time—but is an issue which generally elicits yawns among the voters.

Trump’s goal does not seem to be “repeal and replace.” A more accurate slogan might be “repel and destroy.”

At a listening session on healthcare Monday morning, President Trump said Republicans may be putting themselves in a bad position by repealing Obamacare “because it’s gonna blow itself off the map.”

Many GOP members who retained or took office riding the wave of opposition to the ACA are thinking twice about their support for changes which many of their constituents are beginning to see as threatening to a safety net which they have grown to like.

For similar reasons the Social Security system, the nation’s first broad-based social welfare program adopted in the Roosevelt era in the 1940s, thought radical at the time and frowned upon by anti-tax crusaders, is now practically untouchable.

Since mid-term elections are notoriously unfriendly to incumbents of the president’s party, 2018 could be the moment when the voters may choose to extract punishment for a half-baked plan that is being rushed through hearings, has no way of being funded and which GOP partisans in the House and many in the Senate are strongly challenging.

If the drum roll to replace Obamacare launched the Trump Administration a new national movement appears to have started showing widespread resistance across all voter groups to many of this Administration’s most draconian policies that could ensnare more than just Democrats.

What may be the first big test of Trump’s long term durability will come in 2018—even though he is not on the ballot— when California lawmakers and their colleagues across the nation may encounter stiff opposition to these policies. Healthcare will certainly be high on the list.

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