GOP’s top priority: taking health care away from millions of Americans

We already know that Ryan, McConnell say Obamacare repeal is top priority for Trump presidency, but this is only just the beginning.  With Trump’s victory, GOP hopes to overhaul Medicaid:

Republican control of Congress and the presidency means the GOP can act on its long-held priorities of reining in entitlement programs and repealing President Barack Obama’s health care law, which allowed states to expand the number of people eligible for Medicaid. Thirty-one states have opted for the expansion.

It is not clear what the GOP’s replacement plan will look like. Democrats have warned of dire consequences, and any proposed changes are likely to trigger a fight in Congress.

Last week, the Democratic Governors Association warned that repealing the Affordable Care Act would end health coverage for millions of people and shift the financial burden onto the states, costing them $68.5 billion in uncompensated care over the next decade. The group said the Medicaid expansion alone has provided coverage for millions of Americans who lacked insurance and that it had been a critical tool for states in combating the opioid epidemic.

In 2012, a plan by Ryan to reduce the federal deficit included a proposal to convert Medicaid funding into block grants with a cap on the amount the federal government would provide. Advocacy groups warned that that approach would ultimately lead to fewer people receiving coverage.

The Congressional Budget Office concluded that under Ryan’s proposal, “states would need to increase their spending on these programs, make considerable cutbacks in them, or both.”

Earlier this year, Ryan and Republican leaders offered another, more flexible option: States would receive a fixed amount from Washington for each person enrolled. That approach would allow federal payments to grow if, for example, a recession forced more people onto Medicaid.

More than 70 million are on Medicaid, nearly 10 million of them covered as a result of the expansion.

GOP budget documents say federal spending on Medicaid has increased 200 percent in the past 15 years, and the Congressional Budget Office projects it will climb 68 percent over the next decade to $642 billion. In addition, total state spending on Medicaid is expected to rise from about $216 billion in fiscal year 2015 to more than $337 billion in 2023.

How the GOP overhaul is ultimately structured will be critical, said Matt Salo, executive director of the National Association of Medicaid Directors.

“Some of my members are looking at this and saying if this isn’t done right, if the money doesn’t match what needs to be done, this is potentially the greatest intergovernmental transfer of financial risk in the country’s history,” he said.

States, many of them struggling with budget shortfalls, could end up covering fewer procedures or medications, instituting work requirements or requiring co-pays or premiums. Those that opted to expand Medicaid could decide it’s no longer sustainable.

Paul Krugman of the New York Times writes that the GOP’s top priority is Snatching Health Care Away From Millions:

[We’re] celebrating some very good news. Because health reform, President Obama’s signature achievement, is stabilizing after a bumpy year.

This means that the huge gains achieved so far — tens of millions of newly insured Americans and dramatic reductions in the number of people skipping treatment or facing financial hardship because of cost — look as if they’re here to stay.

Or they would be here to stay if the man who squeaked into power thanks to Mr. Comey and Vladimir Putin wasn’t determined to betray his supporters, and snatch away the health care they need.

To appreciate the good news about Obamacare you need to understand where the earlier bad news came from. Premiums on the exchanges, the insurance marketplaces created by the Affordable Care Act, did indeed rise sharply this year, because insurers were losing money. But this wasn’t because of a surge in overall medical costs, which have risen much more slowly since the act was passed than they did before. It reflected, instead, the mix of people signing up — fewer healthy, low-cost people than expected, more people with chronic health issues.

The question was whether this was a one-time adjustment or the start of a “death spiral,” in which higher premiums would drive healthy Americans out of the market, further worsening the mix, leading to even higher premiums, and so on.

And the answer is that it looks like a one-shot affair. Despite higher premiums, enrollments in the exchanges are running ahead of their levels a year ago; no death spiral here. Meanwhile, analysts are reporting substantial financial improvement for insurers: The premium hikes are doing the job, ending their losses.

In other words, Obamacare hit a bump in the road, but appears to be back on track.

But will it be killed anyway?

In a way, Democrats should hope that Republicans follow through on their promises to repeal health reform. After all, they don’t have a replacement, and never will. They’ve spent seven years promising something very different from yet better than Obamacare, but keep failing to deliver, because they can’t; the logic of broad coverage, especially for those with pre-existing conditions, requires either an Obamacare-like system or single-payer, which Republicans like even less. That won’t change.

As a result, repeal would have devastating effects, with people who voted Trump among the biggest losers. Independent estimates suggest that Republican plans would cause 30 million Americans to lose coverage, with about half the losers coming from the Trump-supporting white working class. At least some of those Trump supporters would probably conclude that they were the victims of a political scam — which they were.

Republican congressional leaders like Paul Ryan nonetheless seem eager to push ahead with repeal. In fact, they seem to be in a great rush, probably because they’re afraid that if they don’t unravel health reform in the very first weeks of the Trump era, rank-and-file members of Congress will start hearing from constituents who really, really don’t want to lose their insurance.

Why do the Republicans hate health reform? Some of the answer is that Obamacare was paid for in part with taxes on the wealthy, who will reap a huge windfall if it’s repealed, even as many middle-income families face tax hikes.

More broadly, Obamacare must die precisely because it’s working, showing that government action really can improve people’s lives — a truth they don’t want anyone to know.

How will Republicans try to contain the political fallout if they go ahead with repeal, and tens of millions lose access to health care? No doubt they’ll try to distract the public — and the all-too-compliant news media — with shiny objects of various kinds.

But surely a central aspect of their damage control will be an attempt to push a false narrative about Obamacare’s past. Health reform, they’ll claim, was always a failure, and it was already collapsing on the eve of the G.O.P. takeover. When the number of uninsured Americans skyrockets on their watch, they’ll claim that it’s not their fault — like everything, it’s the fault of liberal elites.

So let’s refute that narrative in advance. Obamacare has, in fact, been a big success — imperfect, yes, but it has greatly improved (and saved) many lives. And all indications are that this success is sustainable, that the teething problems of health reform weren’t fatal and were well on their way to being solved at the end of 2016.

If, as seems all too likely, a health care debacle is imminent, blame must be placed where it belongs: on Donald Trump and the people who put him over the top.

The reason for all of this: Obamacare was paid for in part with taxes on the wealthy, who will reap a huge windfall if it’s repealed. And the GOP has always hated paying taxes for “those people,” the poor and undeserving. “Perhaps they should die and decrease the surplus population.”