Ezekiel Emanuel is chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania.
The Republicans’ health bill is an act of supreme hypocrisy and insensitivity to the experience of Americans. It will damage — not improve — the U.S. health system.
Obamacare was a failure because it passed with only Democratic votes — so charged Republicans. All through 2009, Democrats tried to get Republicans to engage in discussions about health-care reform. Remember the “Gang of Six” or the “Gang of Eight” that Sen. Max Baucus (D-Mont.) ran to try to craft a bipartisan bill? After Sen. Olympia Snowe (R-Maine) voted for the bill in committee, she reversed herself under extreme Republican pressure. Now, given their own opportunity for a bipartisan health reform bill, Republicans passed a totally partisan bill, and they never even tried reaching out to Democrats to see if there could be consensus.
Democrats are giving insurance companies bailouts — so charged Sen. Marco Rubio (R-Fla.). The Affordable Care Act contained risk corridors, which were a way to spread the risk across insurers when the exchanges just started and no one knew who would buy insurance. In 2014, Republicans voted to block funding for these risk corridors — a main reason that premiums on the exchanges went up so much in 2016 and 2017. Now, in their own bill, Republicans have included tens of billions of dollars for insurance companies. A bailout? No, Republicans re-labeled this a “stability fund.”
Republicans promised they would never allow insurance companies to discriminate against people with preexisting conditions. Well, so much for that. House Speaker Paul D. Ryan’s (R-Wis.) bill allows states to grant companies the ability to charge exorbitant fees to people with preexisting diseases. The Republican claim that no state will pass such bills is ridiculous. Why have the option then? More important, we know states have done much worse in the past. Remember Arizona denying bone-marrow transplants to patients with curable cancer on Medicaid? Who would have thought that could happen?
And those high-risk pools Republicans claim will protect people with preexisting conditions? They don’t work. Even with Rep. Fred Upton’s (R-Mich.) amendment offering an extra $8 billion to the stability fund, the pools would be totally underfunded. Just do the math. Insuring patients with serious illnesses will cost about $10,000 each (a conservative estimate), so Upton’s money covers fewer than 200,000 Americans. Not even a modest fig leaf.
Other Republican axioms: Obamacare is collapsing; the exchanges are dying; premiums are skyrocketing; and a third of counties have only one insurer. Let’s put aside that the Congressional Budget Office and Standard & Poor’s concluded that the exchanges are stable. Let’s put aside that Anthem just announced it is doing well in the exchanges. If they wobble, it is the Republicans’ doing.
A few fixes would enhance the exchanges’ functioning: 1) Enforce the mandate so more healthy Americans buy in the exchanges; 2) guarantee funding for subsidies to consumers so insurance companies can lower premiums; 3) fund the risk corridors and reinsurance payments; and 4) increase targeted advertising so more people know about the subsidies and the requirement to get insurance.
Republicans passed exactly one fix: The stability fund does provide some reinsurance help. But that’s the only thing their bill does to help fix the system. Republicans are undermining and not enforcing the mandate. Republicans decided not to appropriate money for subsidies. And Republicans have severely limited advertising.
This bill will make things worse. It will not improve the number of insured; estimates show that the bill will force tens of millions of Americans to lose coverage.
This bill will increase costs. Cutting essential benefits means people must pay for those uncovered services — whether that’s maternity care, mental-health care or dental care for children. With more uninsured people, hospitals will increase what they charge to cover the uncompensated care they give, driving up premiums. And there is no provision to reduce deductibles.
Most important, this bill has no serious cost control ideas in it. No change in how doctors and hospitals are paid to improve quality and lower costs. No measures to reduce drug prices. No attempts to lower Medicare costs through site-neutral payments — that is, paying the same price regardless of where a procedure is performed — or to prevent hospitals from buying up physician practices to increase their bargaining power and raise their costs.
Republicans promise cost control later, in future legislation. But any additional health-care legislation will require support from Democrats in the Senate. After this hyper-partisan bill, there is no chance a single Democrat will collaborate before the next election.
Desiring to do something, Republicans have only shown hypocrisy and callousness. As polls suggest, they won’t have to wait long to see the repercussions of their actions — only until 2018.
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