The Washington PostDemocracy Dies in Darkness

Trump’s ‘insurance for everybody’ plan has turned deadly

(Matt Rourke/AP)

President Trump promised that the Republican health-care plan would have “insurance for everybody,” but that isn't even true in the realm of alternative facts.

Indeed, according to the nonpartisan Congressional Budget Office, the GOP's Obamacare replacement would cause 24 million people to lose their health insurance over the next decade, nearly doubling the size of the uninsured population to 52 million. Premiums, meanwhile, would rise more than they're already expected to, until, that is, so many older, sicker and poorer people have been priced out of the market that costs would finally start to fall for everyone else. Even then, though, higher and higher deductibles would keep making insurance too expensive for a lot of people to actually, you know, use.

It turns out that freedom really isn't free when it comes to health insurance.

Now, the easiest way to think about the GOP health-care plan is as a three-part reverse Robin Hood. First, it would repeal $883 billion worth of Obamacare taxes over the next 10 years, disproportionately benefiting the rich. Second, it would cut $880 billion of Medicaid spending over the same time, exclusively harming the poor and sick. And third, it would slash Obamacare's health insurance subsidies by $300 billion, and — you might be sensing a theme here — reconfigure the remaining ones to give more help to the young and well-off, and less to the old and worse-off. To take a particularly stark example, the CBO estimates that a 64-year-old making $26,500 would see their after-subsidy premium go from $1,700 under Obamacare to $14,600 under Trumpcare — a 750 percent increase.

That last part explains one of the GOP plan's more surprising “successes.” That's the fact that the CBO doesn't think it would set off a death spiral in the individual insurance market. It seemed like it would, since, unlike Obamacare, it doesn't try to push people to buy insurance by penalizing them if they don't, but rather pushes them not to buy insurance by penalizing them if they do after having let their coverage lapse for two months or more. The problem is that this would give people a financial incentive not to get insurance until they needed it — i.e., when they're sick — which could lead to a situation in which premiums shoot up because there aren't enough healthy people in the market, prompting even more healthy to leave it as well, and so on, and so on.

The CBO thinks something like this would start to happen — but then stop. Why is that? Well, even though it estimates that 2 million mostly young and healthy people would go uninsured as a result of this rule, it expects that even more old and sick people would become uninsured as a result of a system that charges them more and subsidizes them less. That would not only mean a lot fewer people covered, but also a lot fewer people who were expensive to cover — so premiums would come down. In other words, insurance would become more affordable for those who can live without it, and unaffordable for those who can't.

That might sound like hyperbole, but health insurance really does save lives. That, at least, is what a 2014 study in the Annals of Internal Medicine strongly suggests. It found that the mortality rate in Massachusetts fell by 2.9 percent compared to places with similar incomes and demographics after it expanded coverage as part of its own reform that was a precursor to Obamacare. Which is to say that, yes, taking health insurance away from people means some of them will die preventable deaths. And in the case of the Republican health-care plan, it's largely Republican voters who will. According to a New York Times analysis, people who would lose $5,000 or more in subsidies under Trumpcare supported him by a 59 percent to 36 percent margin during the election.

This is peculiar. Political parties usually try to keep their voters alive.

And despite what Speaker of the House Paul D. Ryan might say, it's totally unnecessary. Sure, the CBO says that the GOP's Obamacare replacement would probably stabilize the individual insurance market, but it says that Obamacare probably would, too. Ryan, though, makes it sound like the CBO believes our choice is between his plan that would stop a death spiral and Obama's plan that is causing one. This is a lie. Our real choice is between a plan that would stop a death spiral by taking insurance away from sick people, and one that would do so by subsidizing insurance for the poor and sick.

If Trump really does want insurance for everybody, he's supporting the wrong plan.