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CBO Says 22 Million More Uninsured, But They’ll Pass BCRA Anyway

By  |  June 26, 2017, 08:47pm  |  @stevengberman


When a Democrat was in power in the White House, Republicans could safely craft a healthcare bill like 2015’s AHCRA, in the now-hopeless hope that the King v. Burwell went against Obamacare. Now that Trump is president, the best they can do is keep Obamacare, and add some nice 22-inch chrome wheels to give it bling.

The CBO report on the Senate version of the bill says 22 million (versus the House’s 23 million) fewer Americans would have health insurance by 2026.

Next year, 15 million more people would be uninsured compared with current law, the budget office said.

What is that 22 million number, though?

 

The entire raison d’être for Obamacare was that everyone in America should have health insurance to obtain health care. But America has private health care, not a public system like England. Even Democrats in 2010 couldn’t say they’re going to nationalize one-sixth of the U.S. economy. So they punted and forced everyone to buy something. It failed.

Unfortunately, the healthcare debate isn’t being driven by actual policy, it’s being driven by election politics. This whole thing about a “three-part plan” to repeal and replace Obamacare is pie-in-the-sky fantasizing, as Ted Cruz warned.

And now the GOP plan, both in the House and in the Senate (the Better Care Reconciliation Act of 2017– “BCRA”), keeps the core reason for Obamacare–universal insurance–as its goal, but moves further away from realizing that misguided goal than the original 2010 plan.

The problem is that universal health care and universal health insurance are not the same goal. They are not even close. And Medicaid is not the answer to either problem. America values personal freedom, and part of that is the freedom not to buy insurance, so Republicans are on the right track by removing the individual mandate.

But they’re not considering who the so-called “uninsured” are. Vox interviewed Forbes’ in-house healthcare blogger, Avik Roy. Roy pointed out that of the 23 million fewer with health insurance by 2026 in the House bill, 78 percent of them will be uninsured by choice, according to the CBO. Of those, 5 million will be eligible for Medicaid.

If Medicaid is so important, so life-changing, why is that so many people either have to be fined to sign up for it, or even if it’s handed to them, don’t take it? That is something I think the policy debate has not adequately.

In his Forbes article, Roy criticized Speaker Paul Ryan’s plan for its flat tax credits, which he called a “fatal flaw.” But he found a silver lining in Section 202 of the bill, which has a “transitional” bridge between the original ACA and the new plan, beginning in 2020.

He praised the Senate plan for keeping the “bridge” as a permanent fixture.

But the BCRA has the same problems as Obamacare, in that it doesn’t address health care, it addresses health insurance. And it does so by passing the buck for Medicaid from the federal government back to the states.

The reason that Medicaid’s health outcomes are so poor is because the outdated 1965 Medicaid law places a laundry list of constraints on states’ ability to manage their Medicaid programs. As a result, the main tool states have to keep Medicaid costs under control is to pay doctors and hospitals less and less each year for the same care. Hence, many doctors don’t take Medicaid, and Medicaid enrollees struggle to gain access to care.

Roy applauds the fact that states will have more options to craft Medicaid programs of their own to fit their populations, to open up private insurance markets through “Section 1332” waivers (which were part of Obamacare beginning in 2017 anyway), and to give states a $100 billion (over 10 years) in grants to “shore up” their markets.

Great, but we’re still talking about regulating health insurance, with its enrollment periods and waiting periods and myriad forms and decisions. The Senate bill doesn’t restore a waiting period for sick individuals to prevent them from buying fire insurance after the building burns, so to speak. That is a deal killer for keeping premiums low.

And low premiums is the only desirable outcome of a federal health care plan focused on insurance. Stripping all the trimmings of Obamacare, which transformed the health insurance market in a foundational way, is not going to be possible with such a small Republican majority in the Senate.

So it won’t be policy that shapes the final bill. It will be politics, specifically election politics. Of the 34 seats up for election in 2018, 25 are Democrats. A number of those are going to be competitive elections (such as Heidi Heitkamp in North Dakota, or Joe Donnelly in Indiana). But Republicans also face some tight races: even Jeff Flake and Ted Cruz could face some strong opponents.

If Obamacare is to be repealed and replaced piecemeal, it will happen after 2018. For it to even have a snowball’s chance after 2018, Republicans have to gain several seats in the Senate, and keep their majority in the House. If Republicans don’t pass something on healthcare, they won’t do well in 2018.

Therefore, the Republicans will pass something, and very probably they’ll pass the BCRA. Senate Majority Leader Mitch McConnell will push it with all his might. And he’ll have plenty of help.

The Senate will pass BCRA, the House will come back from recess to finish the job, and before summer is done, President Trump will sign it amid much back-slapping and crowing. And not much will change in 2018 except the campaign ads.