Trump picks signal coming assault on Medicare

Update to The coming assault on Medicare.

The egomaniacal Twitter troll Donald Trump has named Rep. Tom Price (R-GA) as his choice for Secretary of Health and Human Services, which oversees not just “ObamaCare” but the entitlement programs of Medicaid and Medicare. Price supports the privatization of Medicare into “voucher care” that House Speaker Paul Ryan is salivating to pass. Trump names Rep. Tom Price as next HHS secretary:

President-elect Donald Trump has chosen Rep. Tom Price (R-Ga.), a fierce critic of the Affordable Care Act and a proponent of overhauling the nation’s entitlement programs, to lead the Department of Health and Human Services.

Trump also named Seema Verma, a health-care consultant who was the architect of [restrictive] Medicaid changes in Vice President-elect Mike Pence’s home state of Indiana, to run a crucial section of HHS: the Centers for Medicare and Medicaid Services.

As HHS secretary, Price would be the nation’s top health official and the incoming administration’s point person for dismantling the sprawling 2010 health-care law, which Trump promised during his campaign to start dismantling on his first day in the Oval Office. The 62-year-old lawmaker, who represents a wealthy suburban Atlanta district, has played a leading role in Republican opposition to the law and has helped draft several comprehensive bills to replace it.

A former chairman of the conservative Republican study committee, Price has been affiliated with the House tea party caucus and has lambasted what he termed a “vile liberal agenda that is threatening everything we hold dear as Americans.” His congressional website describes him as “devoted to limited government and lower spending.”

His selection drew an immediate rebuke from the Senate’s incoming minority leader, Sen. Charles E. Schumer (D-N.Y.). “Congressman Price has proven to be far out of the mainstream of what Americans want when it comes to Medicare, the Affordable Care Act, and Planned Parenthood,” Schumer said in a statement. “Thanks to those three programs, millions of American seniors, families, people with disabilities and women have access to quality, affordable health care. Nominating Congressman Price to be the HHS secretary is akin to asking the fox to guard the hen house.”

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One of the 18 members of the House GOP Doctors Caucus, Price supports major changes to Medicaid and Medicare, health insurance pillars of the Great Society programs of the 1960s. Under his vision, both programs would cease to be entitlements that require them to provide coverage to every person who qualifies. Instead, like many House Republicans, he wants to convert Medicaid into block grants to states — which would give them more latitude from federal requirements about eligibility rules and the medical services that must be covered for low-income Americans. This plan would also require “able-bodied” applicants to meet work requirements to receive health-care benefits — an idea that the Obama administration has consistently rebuffed.

Some outside groups and watchdogs have warned that such proposals probably would lead to deep cuts for those who use the program. The nonpartisan Congressional Budget Office has estimated that at least 14 million people would lose coverage if Congress revokes the Medicaid expansion that has occurred under the ACA.

[Note: Arizona’s Medicaid expansion is still being litigated in court.]

For Medicare, Price favors another idea long pushed by conservatives, switching it from a “defined benefit” to a “defined contribution.” With that, the government would give older or disabled Americans financial help for them to buy private insurance policies [dubbed coupons or vouchers].

The battle lines are drawn. Democrats See Medicare as Winning Wedge Issue.

Greg Sargent of the Washington Post observes, Obamacare is probably toast. And a lot of poor, white Trump voters will get hurt by it.

Donald Trump has chosen GOP Rep. Tom Price of Georgia, a longtime critic of the Affordable Care Act, as his secretary for Health and Human Services. This likely means that, at best, the health law will be repealed and replaced by something that covers far fewer people, or that, at worst, it will get repealed outright, leaving even more people without coverage.

So what does this mean for poor and working-class white Trump voters who are currently benefiting from the law, some no doubt enjoying health coverage for the first time in their lives?

Jonathan Cohn has a good piece explaining what the choice of Rep. Price means in policy terms. Unlike many Republicans, Price has at least given a lot of thought to how to replace the ACA. But Price’s own replacement proposal would roll back the Medicaid expansion, a substantial portion of financial assistance for others getting coverage, and a fair amount of regulation of the individual market. And so, the likely end result (again, at best) is that a lot of the 20 million people who would lose coverage due to repeal will remain without coverage, and protections for those with bad medical conditions will be eroded.

The core philosophical difference here is that conservatives want far less in government spending and regulations designed to cover poor and sick people, protect consumers and enforce a minimum standard for coverage. As a result, they are willing to tolerate far lower standards in those areas, though some also want conservative reforms to strive to make very cheap bare-bones catastrophic coverage widely available. Liberals think we should spend and regulate to the degree necessary to move toward universal care and see expanded and improved coverage as part of a broader effort to progress toward a higher societally guaranteed minimum standard of living. Conservatives won the election, and apparently, we are now going to do it their way. Elections have consequences.

Indeed, all this should immediately cast doubt on the notion that Trump will clash with congressional Republicans over the future of the safety net. During the primaries, Trump famously said he would not allow people to “die on the street,” which, along with his vows not to touch entitlements, led many to see him as an unorthodox Republican when it comes to the proper scope of government protections for the poor and unhealthy. But now Trump appears prepared to go along with the most conservative congressional Republicans on these matters.

In a later post, Greg Sargent notes that Republicans suddenly discover that Obamacare repeal might not be so awesome, after all:

During the Obama years, congressional Republicans could rail away at the Affordable Care Act and vote endlessly to repeal it, secure in the knowledge that they would never have to deal with the consequences of repeal actually happening. At the same time, they could claim they wanted to keep the popular parts (protections for people with preexisting conditions) without explaining how that might be accomplished while jettisoning the unpopular parts (the individual mandate).

But now, repeal has suddenly become a reality. President-elect Donald Trump’s choice of GOP Rep. Tom Price as Secretary of Health and Human Services underscores that he is dead serious about going forward with repeal-and-maybe-replace. Which means congressional Republicans (who will have to vote on repeal and then later maybe on replace) now have to grapple with the consequences of repeal actually happening — and with the challenges of keeping the stuff people like while blithely tossing out the stuff they don’t.

Talking Points Memo has a good piece that captures the contortions this is forcing Republicans to put themselves through right now. Senate GOP Tips Its Hand: An Obamacare Replacement Could Be A Long Way Off.

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But I wanted to focus for the moment on one particular question: What will Republican legislators from states that have expanded Medicaid do? Note this quote that TPM got from Senator Shelley Moore Capito, a Republican from Trump-friendly West Virginia:

“I’m from a state that has an expanded Medicaid population that I am very concerned about….I don’t want to throw them off into the cold, and I don’t think that’s a strategy that I want to see. It’s too many people. That’s over 200,000 people in my state. So we need a transition. I think we’ll repeal and then we’ll work during the transition period for the replacement vehicle.”

Capito knows that repeal would mean 200,000 of her constituents lose health coverage. And it turns out there are many other GOP Senators in a similar situation.

According to the Kaiser Family Foundation, 32 states have adopted the Medicaid expansion so far. By my count, next year there will be over 20 Republican senators in those states. (The ones that are expanding Medicaid and have one or two GOP Senators are Alabama, Alaska, Arizona, Arkansas, Colorado, Indiana, Iowa, Kentucky, Louisiana, Montana, Nevada, North Dakota, Ohio, Pennsylvania, and West Virginia.)

The interesting nuance here is that before, GOP governors in those states could expand Medicaid even as GOP Senators in them continued to call for Obamacare’s repeal (with nothing happening). But now they will have to cast a repeal vote that actually means taking health care away from untold numbers of their own constituents.

And repeal of the Medicaid expansion is now a very real possibility. Congressman Price — Trump’s pick to head HHS — has offered a repeal plan that rolls it back entirely. Price has offered a replace plan, but some experts think it would likely leave most of the 20 million people who would currently lose insurance after repeal without coverage.

Regardless, even if Republicans do fully intend to try to provide a replace plan that does cover most of those currently on the Medicaid expansion, it isn’t going to be easy, and it’s going to require spending money. That’s why Republican Senators in Medicaid expansion states — such as Capito above — are claiming they are going to transition those people to a new plan after repealing Obamacare, while cautioning that it will take awhile. Others are predicting it could take years.

“Republicans are going to have a tough time coalescing around a replacement plan, and it is going to take time,” Larry Levitt, a senior vice president at the Kaiser Family Foundation, tells me. “This is enormously complicated stuff with difficult tradeoffs. Insurance coverage for millions of people is at stake.”

There was a time when I would have confidently predicted that Republicans who do vote to toss huge numbers of their constituents off of health coverage, without replacing it, would pay a political price for it. I’m no longer sure that’s true. It’s very possible that Republicans may end up repealing Obamacare while vowing a replacement in time that somehow never ends up materializing, because the details prove too difficult, or consensus proves elusive, or the base doesn’t allow it. Alternatively, a replacement that leaves many current Obamacare beneficiaries without coverage is also possible.

Still, you’d think some Republican Senators might be as troubled by such an outcome as Capito at least appears to be, and you’d think some will genuinely wrestle with the policy complications of replacing Obamacare, and in the process will find out that it’s a lot harder than expected. In this sense, at least, consequence-free railing about repeal might have been a lot more fun than actual real-world repeal might turn out to be.

It’s always easier to be a naysayer and to oppose something rather than do the hard work of actually proposing something. The GOP’s post-policy nihilism is so engrained it is difficult to imagine that they will ever come up with a constructive and responsible “replacement” plan to “ObamaCare.” Medicare is one of the government’s most efficient programs. The GOP philosophy is that Medicare must be destroyed because it  demonstrates that government can have a positive influence on people’s lives.

Can social security be far behind?