OBAMACARE OCTOBER 30, 2013
Republicans are outraged that some Americans must give up their current insurance plans because they don't satisfy Obamacare's new regulations for benefits and pricing. Partly they are mad at President Obama, because he repeatedly said people who like their coverage would get to keep it. And that’s fine. As I said yesterday, Obama should have said "most" people, not "all" people. Readers can decide for themselves whether, by the standards of politics, that’s a felony or misdemeanor.
But Republicans are also making a substantive argument here. It’s unconscionable, they say, that lawmakers would force people to give up their current coverage. Just a few minutes ago, during congressional testimony by Health and Human Services Secretary Kathleen Sebelius, an angry Representative Marsha Blackburn from Tennessee practically screamed at the witness: “You’re taking away their choice!”
It’s good politics, I’m sure. It’s also breathtakingly cynical. Republicans have repeatedly endorsed proposals that would take insurance away from many more Americans—and leave them much, much worse off.
Start with the federal budgets crafted by Paul Ryan. You remember those, right? Those proposals passed through the House with unanimous Republican support and were, in 2012, a basis of the Republican presidential platform. Those budgets called for dramatic funding cuts to Medicaid. If Republicans had swept into power and enacted such changes, according to projections prepared by Urban Institute scholars and published by the Kaiser Family Foundation, between 14 and 20 million Medicaid recipients would lose their insurance. And that doesn’t even include the people who are starting to get Medicaid coverage through Obamacare’s expansions of the program. That's another 10 to 17 million people.
And it’s not just people on Medicaid who would lose coverage if Republicans got their way. While Republicans in Congress have not unified by a single alternative to Obamacare, a building block of virtually every proposal in circulation is to equalize the tax treatment of employer-sponsored insurance and individual insurance—which, in layman’s terms, means making it much more appealing for somebody who gets coverage on the job to buy coverage on his or her own. Typically these proposals would allow insurers selling individual coverage to continue some of their current practices, like charging higher premiums or refusing to cover certain services for people with pre-existing conditions, or offering coverage with serous gaps in benefits. Most experts believe such reforms would hike the cost of employer plans, as only sicker people remained on them, potentially creating a “death spiral” that would lead to fewer employers offering plans. (Even the more optimistic estimates assume erosion of employer-sponsored insurance.)
Note the difference in scale here. Nobody knows exactly how many people are giving up non-group policies because insurers are reacting to Obamacare regulations. But it's probably in the millions—and still substantially less than the number of people who would lose insurance if Ryan's proposal for Medicaid became law.
More important, though, look at the kind of change taking place. Almost everybody giving up a non-group policy today has the option to get new insurance either through Medicaid or one of the new Obamacare marketplaces. Some people will pay more for these policies, some will pay less, but everybody will be getting coverage that includes an array of "essential" benefits, limits out-of-pocket spending, and can never be taken away or limited because the policyholder gets sick. In other words, everybody ends up with comprehensive, stable insurance. It may not be the policy he or she has today. But the vast majority of people with non-group market don’t keep the same policy for more than two years anyway.
Under the Republican plan, by contrast, people losing employer insurance would end up in the dysfunctional, non-reformed individual market—the one full of confusing, junk policies that might not cover basic services like maternity or mental health or have huge gaps in coverage. And the people losing Medicaid? They would end up with … nothing at all.
The real issue here isn’t simply Republican opportunism and hypocrisy—although, please, let’s not ignore that either. The real issue is about the true trade-offs of policy. Both sides offer them. With Obamacare, a small number of people lose their current insurance but they end up with alternative, typically stronger coverage. Under the plans Republicans have endorsed, a larger number of people would lose their current insurance, as people migrated to a more volatile and less secure marketplace. Under Obamacare, the number of Americans without health insurance at all will come down, eventually by 30 or 40 million. Under most of the Republican plans, the number of Americans without insurance would rise.
Honest Republicans would justify their policies by arguing that Medicaid is a wasteful, inefficient program not worth keeping—and their changes, overall, would reduce health care spending while maximizing liberty. In other words, forcing people to give up their coverage is worth it. I don’t agree with those arguments, but they are honest. But they should stop pretending that it’s possible to address the problems of American health care without disrupting at least some people’s insurance arrangements—because, after all, they want to do the very same thing.