As they try to stop Republicans from repealing the Affordable Care Act, Democrats have a few central arguments they’re making to explain why repeal would be so catastrophic, none more vivid than the simple fact that Republicans plan to kick somewhere between 20 million and 30 million Americans off their health coverage. This argument has the benefit of being true, and unlike many of the details of health reform, relatively easy to understand.
So how are Republicans responding? With two arguments, both of which are meant to prey on people’s confusion and the complexity of this issue. Once you strip away the deception, both those arguments also reveal just how disastrous it will be if they succeed in their plans for the American health care system.
First: Kellyanne Conway said last week, “We don’t want anyone who currently has insurance to not have insurance.” You’ll notice that most Republicans aren’t repeating this line, for the simple reason that it’s not just false, but spectacularly false. But to really understand what’s going on here, you have to play close attention to how they answer questions about the millions of Americans who would lose coverage under their plans.
The first thing they say is that they want “universal access” to coverage. That sounds good, but its true nature can only be seen in what it’s denying. It’s a contrast to what Democrats want, which is universal coverage — everyone being covered. Republicans want to be able to say that it doesn’t matter how many uninsured there are, as long as access remains universal, in theory anyway.
And if all Republicans mean by “universal access” is that you can get insurance if you can afford it, then we have universal access now. In fact, access is only as close to universal as it is because of the Affordable Care Act. The people who most lack access are the millions of poor Americans unfortunate enough to live in the 19 Republican-run states that refused the ACA’s expansion of Medicaid. And a few years ago, if you had a pre-existing condition and didn’t have the benefit of employer-provided coverage, you didn’t have access to insurance. Even if you did have employer coverage, you could be subject to yearly or lifetime limits on benefits, which means your access could be cut off. That status quo ante will be restored when the ACA is repealed.
So when you hear Republicans say they want “universal access,” you should know that 1) they don’t, and 2) it’s meaningless anyway, unless you think that it’s somehow relevant that Americans have “universal access” to luxury sedans and ski vacations in Aspen. Republicans say their reforms will make health coverage more affordable, thus giving more people access, but they will have to define what “access” means under this scenario before we have any idea even how to evaluate it.
The second argument Republicans make when confronted with the prospect of tens of millions of people losing their coverage is that in the horrific nightmare in which Americans now reside, health insurance is so awful that it really doesn’t matter how many Republicans snatch it away from. Here’s what Mitch McConnell said on Face the Nation:
It is in full-scale meltdown…In addition to premiums going up, co-payments going up, deductibles going up. And many Americans who actually did get insurance when they did not have it before, have really bad insurance that they have to pay for and the deductibles are so high that it’s really not worth much to them. So it is chaotic.
The idea that the ACA is in “meltdown” is ludicrous, but we’ll leave that aside for now. What’s vital to understand is that McConnell and other Republicans have correctly identified the chief complaint people have about health insurance today: high out-of-pocket costs. And if they succeed in their plans, they will make that problem substantially worse.
That won’t be an accident, it will be by design. While we don’t yet know exactly what the Republican replacement plan will be, we know that it will be driven by the principle that if you give people “skin in the game” — i.e., force them to more directly shoulder health care costs — then they’ll become smart consumers and drive down costs. Conservatives believe that over time that will result in lower spending. I and many other people think they’re wrong, but even if you believe they’re right, you can’t deny that increasing out-of-pocket costs is one of the foundations of their ideas about health insurance. To take just one example, they want to get rid of the ACA’s minimum benefit requirements, which state that insurance plans must cover a certain menu of services, in order to allow people to buy bare-bones catastrophic plans, which have — guess what — high deductibles and co-pays!
So on one hand, Republicans are saying, “It’s terrible that deductibles have increased!” while what they actually want to do is increase deductibles. I should also note that the people made most vulnerable by repeal — the more than 12 million Americans who benefited from the law’s expansion of Medicaid — don’t pay deductibles. Which may explain why, as the Kaiser Family Foundation’s Drew Altman has written about focus groups conducted with Trump voters: “Those with marketplace insurance — for which they were eligible for subsidies — saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it.”
There’s a reason why people with government health plans are the ones happiest with their coverage: it’s because they’re comprehensive and don’t involve a lot of out-of-pocket costs. But they have to be paid for with taxes. Republicans are trying to sell people on a fantasy that if we take away the taxes and put the costs directly onto consumers, eventually the system will be terrific. But no one should have any illusions about what they actually want to do.