By Lambert Strether of Corrente.
Let me begin by summarizing (from this excellent post by Jane Timm of NBC) what we might politely call Trump’s intellectual journey on health care policy:
As GOP lawmakers begin the process of repealing President Obama’s landmark legislation, it’s worth taking a look at the eight times Trump has changed his position on Obamacare since announcing his bid for president more than a year and a half ago:
1. Repeal Obamacare. Look to Canada for inspiration.
2. Repeal Obamacare. Cover everybody.
3. Repeal Obamacare, but ‘I like the mandate’
4. Repeal Obamacare. Replace it with something.
5. Repeal Obamacare. Not everyone will be covered.
6. I do want to keep parts of it, we might just amend it.
7. Begin to repeal on day one.
8. ‘Be careful’ — don’t take the blame!
Do Trump’s views even matter? Some answer no, arguing that Trump will just delegate everything to Mike Pence, Tom Price, and the rest of the Republican nomenklatura. We’ll see, but I don’t think The Donald sliced through not one but two party establishments like a hot knife through butter with the goal of handing off power to the Mikes and Toms of this world. So Trump’s views matter. We just don’t know what they are! Interestingly, Zeke Emmanuel met with Trump on health care policy. His reaction: “I found him engaged, curious, and he asked a lot of thoughtful questions and had a lot of opinions, as you might expect.” So, whatever the reasons for Trump’s shifting positions, I don’t see them as random. Or focus-grouped, either. So there’s that).
That said, Trump does seem to want TrumpCare to cover pre-existing condtions (or at least be seen to). Politically, that’s sensible, since pre-existing conditions skew old, and Trump’s base is older. Covering pre-existing conditions is also the right thing to do, as Trump himself seems to recognize:
Trump has consistently supported requiring insurers to cover those with pre-existing conditions, a regulation called guaranteed issue. “I would absolutely get rid of Obamacare,” Trump said in a February 25 during the Republican primary, but “I want to keep [the provision regarding] pre-existing conditions. It’s the modern age, and I think we have to have it.”
(“Guaranteed issue” is the polar opposite of “medical underwriting,” where, in short form, heatlh insurance companies decline to sell you their product if they determine you are likely to use it.) So, millions can breath a sigh of relief? We’ll get to that, but millions there are. From a new study by the Kaiser Family Foundation:
We estimate that . While a large share of this group has coverage through an employer or public coverage where they do not face medical underwriting, these estimates quantify how many people could be ineligible for individual market insurance under pre-ACA practices if they were to ever lose this coverage. This is a conservative estimate as these surveys do not include sufficient detail on several conditions that would have been declinable before the ACA (such as HIV/AIDS, or hepatitis C). Additionally, millions more have other conditions that could be either declinable by some insurers based on their pre-ACA underwriting guidelines or grounds for higher premiums, exclusions, or limitations under pre-ACA underwriting practices. In a separate Kaiser Family Foundation poll,
(If you think about it, life itself is a pre-existing condition. The body is frail, and gets more frail as we age. Shit happens.) So, suppose ObamaCare were repealed tomorrow. How many people with pre-existing conditions would lose their coverage? This is as much as we know:
An estimated 22 million people would lose their insurance if Congress and Trump implemented the changes outlined in the most recent reconciliation bill [that is, the plan proposed by the Republican nomenklatura
The 22 million thrown off the rolls would be disproportionately likely to have pre-existing conditions, simply because they self-selected for coverge in the first place. And many millions adult Americans with employer covered never be covered again if they lose their jobs and with that, coverage of their pre-existing conditions. Terrible optics, even if we leave the moral issue out of it. In any case, covering pre-existing conditions is very popular:
[T[he provision is one of the most popular aspects of Obamacare; it’s favored by 69% of the respondents to a recent Kaiser Family Foundation tracking poll, including 65% of Republicans.
At this point, let me interject that the Democrat establishment is choosing to #resist on behalf of a benefit that is not universal. ObamaCare doesn’t cover everybody, either in reality or in principle, and at best, what the Democrats want to do is return to a status quo ante where millions still suffer and die for back of care, because markets. Well played!
So, pre-existing conditions: We’ll keep them. Which is what the Republicans did when they passed the ” Restoring Americans’ Healthcare Freedom Reconciliation Act” to repeal ObamaCare, which Obama vetoed. Vox:
The bill, introduced by Georgia Rep. and Health and Human Services Secretary-designate Tom Price, left some parts of Obamacare standing, like the requirement that insurers cover young adults through age 26. (That provision is very popular, and possibly harder to tackle through the reconciliation process.) It also left the requirement to cover Americans with partially intact.
The wee problem is that Price’s bill — and Trump doesn’t necessarily agree — also wants to get rid of the ObamaCare mandate to buy insurance or face a tax penalty. (Granted, the mandate is riddled with exceptions, but whoever would have thought that using the IRS to enforce the purchase of a hated commercial product would have created public relations problems?)
The Senate parliamentarian ruled that all the parts of Obamacare that it repealed — Obamacare’s insurance subsidies, Medicaid expansion, the law’s tax increases, and its to purchase coverage — could be dismantled through reconciliation.
Why is eliminating the mandate a problem? Because when you require guaranteed issue but don’t require everyone to buy in, you create a death spiral:
That’s because healthy individuals would often choose to take their chances without coverage. If they got sick, they could buy a plan in the next enrollment season — and then drop it as soon as they received treatment. The likely result: Premiums would skyrocket and only the sickest Americans would remain insured.
So, you need a club to force people into the market (because markets, also freedom) that’s not the mandate. The current Republican candidate — which, again, doesn’t mean it’s Trump’s — is called “continuous coverage.” Price’s bill includes it:
Price’s Empowering Patients plan, like Obamacare, requires insurance plans to offer coverage to all patients regardless of how sick they are. But the Empowering Patients plan, unlike Obamacare, would let insurers charge sick people more if they did not maintain “continuous coverage.”
ObamaCare Facts gives the detail on how “continuous coverage” would work, as proposed by Price’s bill:
In simple terms, the “Continuous Coverage Exclusion” says “if you don’t have continuous coverage, you don’t have guaranteed issue coverage!”
More specifically, the “Continuous Coverage Exclusion”:
- Makes it so insurers can charge you more and exclude coverage preexisting conditions for up to 18 months upon entering a contract (an 18 month preexisting conditions exclusion period”, see page 150 of Price’s law for his version).
- … but only if you have a gap in coverage of more than 63 days before entering a new contract.
- Meanwhile, anyone who can’t get private coverage can buy into a high-cost sick-pool.
So it turns out that TrumpCare creates second-class citizens, just as ObamaCare does, but using a different mechanism:
CONSIDER: If you forget to pay your bill because you changed your charge card, you can be priced out of coverage for life and have to pay a higher fee for life under this plan. You could also have a lapse in coverage if your insurance application or payment was lost by the bureaucracy. A person could get sick, forget to pay their bill, get dropped, then have to wait 18 months to get treated and die waiting under this plan. The only alternative would be a high-risk pool (an insurance pool for those with pre-existing conditions) which would likely charge very high rates and be state run. Thus, sick people would be forced into high priced government-run healthcare if they wanted to survive, while the rich and healthy would get to continue their plans at lower rates. Please note that “lower rates” are essentially the only benefit of excluding sick people in this way.
And do note that insurance companies have every incentive to game “continuous coverage” by “losing” your payment, sending correspondence to the wrong address, and so on. Given good enough IT, medical underwriting would creep right back in, just as it has under ObamaCare with narrow networks and pricing by zip.
I know it will never happen, but I’d love it if Trump decided to stick it to zombie-eyed granny starver Paul Ryan and smarmy liberal goodthinkers Pelosi and Schumer by lowering the age-limit for Medicare to zero by executive order. Why not? That flight of fancy aside, it’s good that covering pre-existing conditions is a bipartisan consensus — even if a universal benefit like simple, rugged, and proven Medicare for All is not. We’ll have to watch how badly the Republicans screw us, and how complicit the Democrat establishment decides to be.
 Times-Picayune: “My childhood home was destroyed by a tornado two days before Christmas in 2015. The insurance agent who brought my father a check told him that he’d been a great customer. Why? Because my parents had been paying for insurance since 1979 and hadn’t filed a claim until that tornado. On the other hand, when my house was destroyed by floodwaters in August 2005, I was quickly deemed a bad customer. I told my car insurance agent that I wanted to buy a renter’s policy from him, and he said he couldn’t sell me one. ‘You filed a claim after Katrina,’ he said.” So, like that.