Now that we know Rep. Tom Price (R-GA) will be the next Secretary of Health and Human Services, it would be a good idea to look at the mechanics of his Obamacare Repeal and Replace bill. We did this in 2015 for HR2300 and I am reprinting the post on distributional impacts below. The mechanics of the plan are described in this post:
TLDR: The plan is good if you are healthy and wealthy as there are a ton of tax breaks and tax shelter expansions through HSA expansions. If you are chronically ill or poor, you are significantly worse off. And now for the moldy oldie:
Yesterday I gave a brief overview of how Rep. Tom Price (R-GA) HR.2300 would work. The “plan” is to repeal everything related to health insurance in ACA and the reconciliation bill, and then replace it with generous tax treatment to savings, high risk pools, small subsidies by age for use on the individual market, selling insurance across state lines and tort reform pixie dust. He funds the plan with a modified Cadillac Tax. So who wins and who loses from this proposal when compared to the baseline of current law.
Repealing all of the ACA
This is the largest source of people who will be made worse off. The big changes are the killing of Medicaid expansion, the re-opening of the donut hole, and underwriting changes.
Anyone who is newly eligible for Medicaid due to expansionwill be far worse off. At best they will transition from very affordable or free high actuarial value coverage to unaffordable junk coverage with $10,000 or more deductibles. More likely, most of these people will become uninsured as they have made the determination that food, rent, heat are more immediate needs than healthcare on a limited budget.
Senior citizens who are moderate to high prescription drug users will also be worse off. The Donut Hole in Medicare Part D is scheduled to be closed entirely by 2020, and it is significantly smaller and hitting fewer people now than it did in 2009.
Underwriting changes are significant. The ACA/PPACA has guaranteed issue/partial community rating (age/geography/smoking bands). That means a 24 year old non-smoking woman pays the same as her 24 year old non-smoking male roommate. Premiums are banded so a 64 year old can not pay more than three times the premium of a 21 year old. Under Price’s plan, guaranteed issue and partial community rating go away. Instead, insurers are allowed to charge whatever they want and to underwrite with price discrimination. There is a minor carve-out for continuous coverage through Section 134 but if there is any coverage gaps, people will face full medical underwriting to get back into the market. Job lock will be back with a vengeance.
Repealing PPACA makes poor, women, sick, 50 to 64 year olds, Medicare beneficiaries and people not employed by larger employer groups worse off. On the other hand, young men with no pre-exisiting conditions and decent incomes are better off as they don’t have to pay for pregnancies any more. Additionally, the very well off who are paying higher taxes are better off as those taxes disappear. This is not surprising as it is why the Americans for Prosperity anti-Obamacare ads sucked last year:
There are a couple of categories of people who are undeniably worse off under Obamacare than they would have been under a no change policy. They can be clustered into a few broad groups.
- People earning over $250,000 per year in Modified Adjusted Gross Income who have employer sponsored health care or Medicare and are paying more in taxes
- Young single males with absolutely no health problems, no relatives with health problems and incomes over 250% Federal Poverty Line that previously had a $42 a month, $25,000 deductible plans that did not cover maternity or mental health needs. Those policies got cancelled and they actually have to buy good insurance. Young guys making under $25,000 a year usually will get decent subsidies, past that, it is hard to be sympathetic to someone bitching that they (a member of a high accident group) have to buy decent insurance. Avik Roy has been trying to make this class sympathetic and failing miserably)
Those are the two big classes of losers under the law. Neither are particularly sympathetic.
The New Plan
Once the ACA has been repealed, the replacement component has even more distributional implications. Subsidies, tax treatment for HSAs, Cadillac taxes and how the Price plan deals with high risk and high cost individuals are the major points I want to cover.
The first thing to look at is the subsidy/tax credits (they are the same damn thing) being offered by ACA and Price.
I looked at Atlanta pricing as it is near Rep. Price’s district, and it is not wildly divergent from typical experiences, as well as Cheyenne, Wyoming as that is one of the more expensive markets in the country. I used Healthsherpa.com for the premium subsidy offered to a non-smoking, single individual at different ages. 
Yellow bands indicate where a person receives more money from Price than from PPACA. In Atlanta, anyone who makes under 150% FPL receives more money in PPACA advanced subsidy tax credits than they would receive from Prices’ plan. The same applies in Cheyenne. If anything this chart significantly understates the amount of subsidy people who make under 150% FPL receive as it does not include the Cost Sharing Reduction (CSR) subsidy that bumps the actuarial value of Silver plans from 70% to 94%. But even with that concession anyone who makes under 150% is most likely worse off.
People who make 300% FPL are a bit more complicated. People under age 58 in Atlanta get slightly more money from Tom Price’s plan than they do under PPACA. People under age 42 in Cheyenne get more money from Price than from PPACA subsidies.
People over age 55 and in the individual insurance market are significantly better off under PPACA than they are under Price for multiple reasons. Price lifts the premium banding restrictions as PPACA is repealed. This means premiums for comparable policies for a 55 year old will be much higher for a perfectly healthy 55 year old in Price’s world than under current law. Premiums for a 64 year old who is perfectly healthy will be five to eight times more than the premiums of a perfectly healthy 21 year old instead of the three times more healthy. Note that I am specifying perfectly healthy. If a 55 year old or even more so a 64 year old has an actual medical history with pre-exisiting conditions such as getting old, insurers will either significantly upcharge them from a base rate of three, four, five times that of a 21 year to ten, twelve or fifteen times that of a perfectly healthy 21 year old or not cover them at all if they can find a way to do so. As a side note, the medical recission regulations in PPACA are repealed, so insurers will again start going through 15 years of medical records to find reasons to deny claims after the fact and cancel policies due to non-disclosure of acne as a teenager.
The subsidy plan makes people who make under 150% of poverty line universally worse off as either their subsides are much lower or Medicaid expansion is gone. Young and healthy people who are making 300% or more FPL are slightly better off. Healthy people of all ages who make more than 400% FPL are better off as they’ll qualify for an individual market tax credit in Price’s plan instead of being disqualified by income for subsidy under PPACA. Healthy people in general will see lower premiums due to the resumption of medical underwriting. Any one who is sick or has a history indicating higher future expenses (two slightly different things) will probably be worse off as their premiums will soar.
Price will argue that premiums under his plan will on net decrease and thus affordability is not a concern. Premiums will decrease because covered services will decrease for two reasons. The first is that he got rid of all Essential Health Benefit requirements in repealing the ACA. That means mental health, maternity, contraceptive and preventative screening care will be voluntary add-ons to coverage with massive adverse selection in pricing (Only women who think there is a decent chance they’ll be pregnant in the next eighteen to twenty four months will buy a maternity rider etc).
Secondly, he wants to replicate the credit card regulatory environment for health insurance. If a plan is approved in one state, it can sell in any state without the second state imposing any additional coverage burdens. That means within eighteen months of this law being passed, one small, easily bought state government will be home to 98% of the nation’s health insurers as they’ll do whatever it takes to please their new job creating overlords. Mississippi or South Dakota or Delaware will then impose their minimalist regulatory burden that won’t require coverage for autism, won’t require coverage for addiction rehab, won’t require coverage for anything expensive and politically unpopular. It will be a Gresham law situation where any insurer who does offer decent coverage will death spiral out.
These changes means that a young, male with no medical history will again see $57 a month policies for $10,000 deductibles. They’re a winner until they are either not young or have a medical history. Anyone else is probably no better off and potentially significantly worse off as they’ll either be uninsurable, their needs won’t be covered or their rates will significantly increase.
HSAs
Health Savings Accounts are a primary focus of the Price Plan as well as most other Republican health care ideas. The idea is to put people in control of their health care spending by having people covered by very high deductible, low actuarial value plans while allowing them to save money in a tax advantaged account. High deductible plans are great from a Republican point of view as long as they are proposing them but evil when Silver plans have high deductibles, but that is another post for another day. There are a couple significant HSA policy changes. Right now, a single person under age 55 can contribute up to $3,350 while someone over age 55 can contribute up to $4,350. HSAs are restricted to spending on prescribed medical care and limited non-prescription items.
Under Price’s plan, the HSA contribution limit is moved to the maximum limit to an IRS retirement account contribution limit. I am not sure if the apporiate limit is the combined IRA/Roth IRA limit of $5,500 for people under age 50, or $6,500 for people over age 50 making catch-up contributions, or the $18,000/$24,000 for Under-50/Over-50, or something else. I am not a retirement expert.
In any case, bumping up the contribution limits only helps people who are already maxing out their current contributions. That means the benefit will be overwhelmingly concentrated for people who make over 400% FPL who are looking for a tax advantaged savings vehicle. The tax advantaged nature of the HSA means a person who makes poverty level wages might see a $50 federal subsidy on their $500 HSA contribution (the odds of a person in this situation actually having an HSA is low), while someone making $500,000 a year will see a $350 federal subsidy for an marginal increase contribution of $1,000 to their HSA.
So the HSA scheme is a massive transfer of resources to the well and very well-off.
Cadillac taxes
As we all know PPACA has the Cadillac tax. It is a 40% surcharge on the incremental dollars for policies that cost more than certain thresholds. In 2018, those thresholds are $10,200 for individual coverage and $27,500 for family coverage. It is scheduled to increase at CPI-U+1 for 2019 and then CPI-U. Price’s plan modifies the Cadillac tax by reducing the thresholds but decreasing the tax rates.
Sec 131: Allows for the employer exclusion of health care coverage up to $20,000 for a family and $8,000 for an individual, with any additional funds used to be taxable dollard….
The threshold changes are important. In 2013, employer sponsored coverage for individuals averaged $5,500 and family coverage averaged $16,000. To hit the Cadillac threshold, the average plan premiums from 2013 would need to grow annually at 13% for individuals or 11.5% for family coverage. Right now we are seeing growth rates of less than 5%. Bringing the thresholds down to $8,000/$20,000 changes the growth rates needed to hit the thresholds down to 7.8% for individuals and 4.7% for family premiums. Family premium growth is roughly the sum of real growth plus inflation.
These threshold changes mean most employer provider health plans will have some portion of their premiums taxed within a few years even in a low premium growth environment. This means families with slightly above average premium plans will see their wages decrease as their health insurance will be partially taxed under Price but not under PPACA. This difference in rates will benefit individuals with very rich benefits but low cash wages. It is probably a wash to slight disadvantage for people like the Cruz family with their $40,000 a year policy from Goldman Sachs as they’ll pay a slightly lower rate (35% to 39.6% vs. 40%) on a larger increment.
(NB: From a behind the veil build a system from scratch, clawing back the employer tax exclusion for health insurance premiums is a good thing, but the transition in front of the veil is a nasty problem with significant distributional issues.
High Risk/High Cost Individuals
PPACA deals with high risk/high cost individuals by using community rating, subsidies and participation enforcement through a soft personal mandate to build big risk pools that can absorb the costs of people with consistent $30,000, $100,000, $500,000 or million dollar claim years. Price plans to deal with these people in two ways. The first is to block grant $1 billion dollars a year for four years (or $2.2 million per Congressional District per year) to help states fund high risk pools. The second is to create re-insurance pools where the states agree to pay claims above a certain level and taking the high cost tail risk off of private insurers. Re-insurance is part of PPACA as a short term bridge function. Historically state based re-insurance pools are under-funded with high premiums, long waiting lists, and limited benefits. For instance, the Tennessee high risk pool (ACCESS TN) in 2014 had a maximum annual benefit limit of $250,000 for medical expenses and $100,000 for pharmacy and a lifetime limit of $1,000,000. There are numerous conditions which can burn through either of those limits by mid-March.
The Price Plan makes people with high cost, chronic conditions far worse off as either their premiums will be far higher for far skimpier benefits, or they’ll be waitlisted for access to limit care via the high risk pool.
Wrap-up
The typical person who benefits from the Price Plan on net are families making more than $200,000 with employer sponsored insurance as they’ll see lower taxes and expanded tax shelter opportunities in the HSA. Additionally, young men with no medical history will see cheaper premiums for equivilant or worse plans. Individuals who are sick, poor, and/or female will be on net worse off. Seniors on Medicare with moderate prescription drug usage will be worse off as the donut hole re-opens.
Sab
For those youngsters reading this, when I got out of high school in 1972 my dad who was a doctor tried to get me health insurance because he thought it was important for my future financial stability, and we discovered that insurance companies would not cover women. I kid you not. This actually happened to me.
Fair Economist
This is basically a return to what would have been the status quo – and after a few more years of decay, it mostly means the collapse of the individual health market. Do the Republicans think about the effects on rural communities? The ACA medicaid expansion kept a lot of rural providers alive, and to lose that plus the Exchanges all at once is going to put a lot of them out of business. There will also be a lot more money flowing out of rural areas and that’s going to be a hit on the economy as well.
Schlemazel
This goes back to a comment I made to Ozark on this morning’s thread. Conservatives can never see bad things happening to them or feel the pain others feel when bad things happen beyond their control. To them it is always that ‘losers’ had it coming for some reason that makes it avoid them.
rikyrah
Thanks for this Mayhew. I feel such sorrow reading this. This means DEATH for a whole lot of people.
EVIL AZZ MUTHAPHUCKAS.
Kay
Well, this is very moderate and not-Republican!
We basically got a dumber and more corrupt Ted Cruz in the White House, along with a far Right rubber-stamp Congress.
So much for “Trump is different”. Some fucking “revolution” this is. It’s hard Right Republicanism wearing a ball cap.
Kay
All the pundits who said Trumpism was somehow different than robber baron Republicanism will resign now, right?
We wuz robbed. Same shit, slightly different package. Great marketing, though.
Stillwater
Thanks for writing this Richard. Well done.
Pogonip
@Sab: What was the stated reason for ignoring such a huge customer pool?
Kay
We are so screwed. Why do multi-millionaire cable tv celebrities hate Medicare so much? It’s not like they pay any more than anyone else for it.
Is it just the tax breaks they’re all shilling for, or is it hatred of the middle class?
CaseyL
@Kay: That’s what his supporters wanted – at least, the ones who have always voted GOP and will always vote GOP because the only thing they care about is paying the lowest taxes possible.
The rural poor who will be hurt are mostly (though not all) the rural poor in Red states whose Governors opted out of the Medicare expansion: they never had the benefit, so they won’t notice they still don’t have it. That other people just as poor as them are losing it only makes them happy as those other people “didn’t deserve it anyway.”
StringOnAStick
One thing my husband and I realized on election night was that his plan to become a contractor to his company and work part-time after age 60.5 is now utterly DOA since we won’t be able to afford to buy health insurance. We’re both 58, with plenty of knee and back issues between the two of us, plus I’m female so, you know, un-insurable even without the uterus I got rid of years ago. After watching his last two close family members die this year and too many friends before that, my husband was determined to try to live more life by working less before the grim reaper comes for us as well. Oh well.
As a direct example of why this stuff matters, my boss’s 18 year old son broke his neck this past July and is now a quadriplegic. They had excellent insurance through his wife’s job (what he could buy as a DDS in an individual practice was 4X as much and not as good); the current total billing for his care is just under $2 million. What his son lost with this election was all the good things from Obamacare that would keep him on his mom’s insurance and not let him be refused for insurance after age 26. So, that rather sucks. My boss was at his hockey club and had bit his tongue since the election since so many of the other players (mostly fellow professionals) had been high-fiving about the orange shitgibbon since the election, but he couldn’t take it anymore so he mentioned these things that I just listed about his son’s future care. These guys are generous to who they know since they helped raise most of the money for the kitted-out van they now need to transport their son, but their main complaints against the ACA were (1) they shouldn’t have to help subsidize the cost of someone else’s insurance, and (2) if people want to have health insurance, they should get better jobs. The amount of selfishness and privilege in those two attitudes, plus the shear inability to understand how insurance works (and some are MD’s) says all you need to know about why this asshole won the electoral college.
MomSense
This is a nightmare. So many people are going to die.
hovercraft
Just like every other GOP plan it’s designed to move money upward to their masters.
Given the election we’ve just had and the “economic anxiety” that was supposedly the cause of the Shitgibbons win, don’t they feel the need to make even perfunctory gestures towards these people? I know that Obamacare has been completely distorted in the eyes of the majority of their voters by the GOP, with the media playing right along with them. If anything the media’s handling of Obamacare was a precursor for how they handled this election. They refused to spend the time understanding what it was, and they amplified every single lie that the GOP spread about it. Instead of reporting that yes premiums were going up each year, but they were going up at a slower rate than before the passage of the law, they became the GOP megaphone for the “law is terrible and is going to kill you”. Every little bump was turned into the biggest catastrophe ever, the need for the one minute story with both sides represented caused the plan to become distorted in the eyes of far too many Americans eyes. They let the GOP get away with the promise to keep all of the popular parts while doing away with the mandate, which is just not possible. Instead of saying that every single time it was mentioned, just as they mentioned e-mail and server every time they mentioned Clinton’s name, they just let GOPers get away with the lie, so now America like Kentucky are about to learn that they can’t have their cake and eat it too. Black Hitler actually did do stuff to help the economically anxious people too, not just those people. The Shitgobbon is the culmination of the medias failure, but it’s been doing this since Nixon, and now it deserves to die, people are literally dying because of the medias incompetence.
Juice Box
Gov. Ronald Reagan signed tort reform laws in California which has made California’s medical care super cheap. Not.
California, which has a population larger than Canada, doesn’t need to allow insurance to be sold across state lines to achieve those capitalist economies of scale because its health insurance is already cheaper than Canada, which has 13 provinces. Not.
Are those people completely resistant to facts?
Kay
This will harm the white working class where I live the most, but you-all knew that.
It’s hard for me to muster up a lot of sympathy for them. Trump was and is a liar and that was obvious to any person with a pulse and they’re not stupid.
They wanted to believe this crook and now they’re going to pay dearly for it. I’m just sorry they drug the rest of us down with them. Good job, dopes. Now no one can have Medicare because of your stupidity and eager willingness to be conned.
Raven Onthill
I think sleep deprivation during residency neurologically disables MDs.
Mr. Mayhew, how did insurance company employees live with themselves before the ACA? That’s an appalling question, I know, but it seems to be the time for appalling questions.
Barbara
I keep getting contacted by AARP and I was going to send them a snarky email, but I logged on to the home page and found the following:
http://www.aarp (dot) org /politics-society/advocacy/info-2016/where-aarp-stands-on-medicare-social-security (dot) html?intcmp=AE-HP-FLXSLDR-SLIDE1-RL1
Throughout the debate about the future of Medicare, be assured AARP will fight to ensure that any legislation is based on these critical principles:
Medicare should be strengthened and improved so both current and future generations can count on having access to high-quality, affordable coverage.
Medicare should continue to guarantee a specific set of benefits that are affordable and meet a person’s health care needs.
Medicare should offer choices that ensure access to high-quality health care.
Medicare should improve the quality, safety and efficiency of care by emphasizing value and cracking down on fraud, waste and abuse.
I highlighted the one that is the most important for this debate. You can also sign up for AARP’s e-advocacy newsletter, which I am doing. This will likely give you much more current information than you will get through newspapers or other news sources.
the Conster, la Citoyenne
Never leaving Massachusetts I guess, where we’ll go back to Romneycare.
Keith G
Well, it certainly makes planning for my old age lot easier knowing that if my cancer returns, as it might in the next 7 – 12 years, it will kill me.
Ghost of Joe Liebling's Dog
@Kay: The simplest explanation – albeit cynical : They hate us and want us to die.
Haven’t seen anything that fits the observable facts better, though I’d be glad to be wrong.
With kind regards,
Dog, etc.
searching for home
Barbara
It is a conceit of doctors like Price that somehow they are held back by public insurance programs, when, in reality, they make much, much more money than they ever would without them. Doctors who talk about market forces mostly don’t know what they are talking about. What they actually mean is the kind of market where they get to set prices and no one gets to demand enough information to actually compare them (assuming that would be feasible). The only question here, in my mind, is how pissed off the insurance industry will be with the level of uncertainty that is being imposed on them by people who have never worked for an insurance company let alone run one.
Sab
@Pogonip: That we would all get married in a couple of years so they didn’t want the risk of young women we ho knew that they might need insurance as opposed to the millions who thought they would be healthy until they got married. Apparently if you were bright enough to know you needed insurance at age 22 it proved you had a secret underlying condition. Also unexpectedly pregnancy was a concern my. Later they solved that problem ed m bIi lOoy not offering maternity coverage at all.
Steve in the ATL
@Juice Box:
Surely you know the answer to this question.
hovercraft
@Kay:
They’ve all bought into the bs that “those” people aren’t pulling their weight. Remember the only thing that motivates “those” people is tough love, unlike the rich who need to be handled with kid gloves to prevent them from taking their ball and going home, the poor must be deprived of every hint of a safety net to get them to work harder. They have worked hard for what they have, and want to keep every last dime they can, if you are not as well off as them you obviously haven’t tried hard enough. Never mind the advantages and breaks they’ve had, racism, structural disadvantages, sexism, and whatever other excuse you want to make are not a factor. They are paying their “fair share”, even if their accountant is using every loophole available to the rich to reduce that share, and so should you. The 47% comment didn’t come from nowhere.
Kylroy
@Pogonip: Not that they had to articulate it, but I’m going to guess pregnancy and generally higher claims.
Stan
Mark my words: Everything bad that happens as a result of repealing Obamacare WILL BE BLAMED ON OBAMACARE.
Sab
@Sab: I dislike auto correct which is mostly stupid
greennotGreen
I was hoping that new discoveries in cancer therapies would keep me alive, but looks like without Medicare I’ll just run out of money first.
Sarah Palin was right about the Death Panels, just not who would institute them.
the Conster, la Citoyenne
Shouldn’t we all demand our contributions back? I’ve been paying into Medicare and Social Security for 45 years. I could use that money now that I’m 61.
Cermet
These fuckers do care – they care that the kock-sucker’s want slaves to wages and health care as provided by their companies – no one will dare change jobs or fight for better wages if health care is at stake – this is why ACA was the most dangerous piece of legislation ever enacted and had, at all costs, be killed. Their plan will work for a while but will, in time, backfire. But the terrible consequences for so many who will now suffer is hardly worth the price. Damn them – hope someday, someone they screwed will deal with them in a manner such low life floating shit deserve.
gene108
Employers like some level of regulatory stability. They just adapted their systems to the existing PPACA. It will cost them money to adjust to the Republican plan.
Wouldn’t this be an incentive to maintain the status quo?
Sister Rail Gun of Warm Humanitarianism
@the Conster, la Citoyenne: I know people who support dismantling Social Security because they think they’ll get their “savings account” back to invest as they please.
D58826
At one level I would like to say to a Trump voter who loses a loved one due to lack of medical car – I SPIT ON HIS GRAVE. But even Trump supporters are human and do not deserve that. While not a particularity devote Christian Math. 25 it it injunction that what you do to/for the least of Christ’s children you do to/for him seems like a good way to live. Our Bible spouting conservatives should try it sometime
Barbara
@hovercraft: Look, Medicare as currently configured has some serious issues regarding its sustainability even in the medium term. No one is making that up. Currently, the average Medicare beneficiary is receiving services that cost the government three times the total amount of tax expenditures that were contributed by that beneficiary. (Whereas, Social Security inputs are pretty close to its pay outs, making tweaks a totally feasible solution.) The delta for Medicare is made up by wage taxes from employees who are not current beneficiaries. This IS a problem. My own view is that if anything like Ryan/Price plan were to pass it would be increasingly difficult to persuade current workers to pay wage taxes — potentially for decades — to support benefits for other people that they will never have access to. I suspect that current beneficiaries also are extremely nervous about this, and that’s why, traditionally, they have opposed such plans even when they hypothetically exempt current beneficiaries. That exemption is not any more sustainable than the current program is.
So something does need to be done. But Ryan’s view that market competition will somehow come to the rescue like a magic pony is utterly ridiculous and downright fraudulent. Basically, the U.S. pays too much for too many services. The asymmetry of information between purchaser and provider is too high for the market to correct either of those things. When the burden is placed on insurers to do that, providers and insureds both go straight to legislators and demand changes. Moreover, bifurcating the program by year of eligibility sustains some of the worst features of Medicare in stoking overutilization and high costs, which will make vouchers even harder to support politically. So even if you were to consider vouchers as potentially useful you would need to continue addressing the high expenses and high utilization that did so much to make the program grow out of control in the first place, whether it’s hospital expenditures or drug expenditures.
Anonymous At Work
Richard,
My read on Rep Price is that he is to the hookers-and-blow era of medicine what Tom Delay is/was to DDT/who cares? era of pest control. Accurate?
D58826
@Barbara: Well one fix that has been proposed repeatedly is to eliminate the wage cap on the soc.sec./medicare tax.
BretH
@MomSense: Alan Grayson turned out to be quite an a-hole, but he was spot-on with this one. I have yet to see a clearer explanation of the Republicans’ health care strategy:
Don’t get sick
Woodrowfan
Generally I have found this to be true if they talk about ANYTHING outside of their medical specialty.
Barbara
@D58826: The Medicare component of the wage tax doesn’t have a wage cap. That was eliminated many years ago.
Woodrowfan
@D58826: getting rid of the wage cap would solve a lot, or even just raising it. we rather enjoy the cap now–my wife’s paychecks suddenly goes up a LOT in October. But I’d rather have a stable SS system than an extra pay bonus for the last 2-3 months of the year.
WereBear
@Woodrowfan: Indeed; Barbara’s point is a good one. How are they going to make money when people don’t have any?
hovercraft
Those ‘economically anxious’ voters are set to be the biggest casualties of the Tom Price plan.
SAD!
Obamacare is probably toast. And a lot of poor, white Trump voters will get hurt by it.
By Greg Sargent
The repeal of Obamacare should make the economically anxious much more secure going forward, seeing as they will now have the freedom to once again enjoy lives free from the burden of health insurance.
D58826
@Barbara: ok
Kylroy
@gene108: Insofar as employers are rational, yes. Given how business supported all efforts to destroy the ACA, however…
D58826
OT but der Fuhrer looks like he has made peace with Mitch McConnell. The report is that Mrs. McConnell (i.e. former sec. of Labor Elaine Chao) as sec. of transp.
But look at the bright side – at least no traffic problems on the GW bridge.
I guess that is why Mitch wasn’t concerned about draining the swamp.
Brachiator
Richard, thanks very much for this analysis.
A few questions/comments
Why do these dopes insist on claiming that tort reform will save billions and billions of dollars? Are there easily understandable studies that put this into perspective?
I think I understand what junk coverage is, but am not sure exactly what types of plans you mean. Was the Obamacare definition of minimum essential coverage meant to avoid this by mandating a level of medical care that would be available for all who were covered by the health insurance law?
Good point. Many people did not know about the increased taxes on high income taxpayers that helped underwrite the ACA.
MomSense
@Brachiator:
The dopes don’t care if what they say is actually true or disproved. They say it anyway to justify their policies knowing full well that their constituents and our media won’t hold them accountable.
Botsplainer, Cryptofascist Tool of the Oppressor Class
@Anonymous At Work:
Ironic you mention DeLay. Don McGahn, DeLay’s lawyer who gave him all the advice to do whatever he wanted has now been tapped to be White House Counsel.
Brachiator
@Ghost of Joe Liebling’s Dog:
Not all of you. And not right away.
Richard Mayhew
@Brachiator: Tort reform defunds a major Democratic donor group… that is the objective.
The essential health benefits of PPACA meant preventative care had to be covered, it means mental health care has to be covered, it means pre-natal and pregnancy care has to be delivered. Get rid of those coverage mandates and a healthy 23 year old man can get dirt cheap coverage.
mai naem mobile
@D58826: on Twitter they’re saying DOT is going to I shit you not, Chris Christie.
Poopyman
@Cermet:
I’m thinking that the number of desperate people who see no way out – maybe a terminal diagnosis, maybe financial destitution – are going to be legion. Thousands will see no way out. Hundreds will decide to lay the blame where it belongs. I’m thinking there could be lots of suicidal folks who decide to take the mofos with them.
Interesting times, folks! Watch the unintended consequences unfold!
Botsplainer
@mai naem mobile:
Elaine Chao, I thought.
Kay
@hovercraft:
Trump was presented as delightful entertainment. No one was supposed to take what he said “literally”. It was all fun and games.
Now they’re going to pay for that entertainment. They’re already forgotten. The White Working Class were a fad. Now we’re back to the White Upper Class- serious bizness.
That’s what “dance with the gal who brung you” means. Democrats brung them all these programs. They went off with Trump and now they’re screwed.
hovercraft
@Barbara:
I agree with your analysis, but as you say the nothing that is being suggested by Ryan or Price would fix the problems. The most responsible thing to do is to eliminate the profit motive, insurance companies are not truly necessary, and the drug companies are gouging us all. I understand developing drugs is costly, but as evidenced by the several recent instances of jacking up prices for no reason at all, there is a great deal of price manipulation going on. The government already does a great deal of R and D, why not put more tax payer money into that, it would be cheaper than the current system, let the government hold the patents, and then let drug companies manufacture the drugs at a much smaller profit margin. There are ways to reduce the costs, while maintaining the quality, I don’t think any of this will happen now, but since it’s pretty much a given that Obamacare will be repealed, we need a plan B. Maybe after 4 years of whatever comes next, people will be more receptive to a plan that goes after the insurance and drug companies.
As you said Medicare and Medicaid are going bankrupt and have been for a long time, the costs of all medical care must be brought down, or we will all be in the same position as those two programs. The cost of medical benefits is a key component to the wage stagnation that has occurred over the last thirty years, while it’s true that companies have been pushing more and more money to the top, what little they have given to workers has largely been in the form of worsening insurance policies (more expensive and poorer coverage). None of our health care system is sustainable.
D58826
@mai naem mobile: hmmm. different twitter feeds. I had seen that bridgeman was holding an 11:30 presser.
May we live in interesting times.
Poopyman
@Kay:
They had their brief moment of fun, and now we’re all stuck with the social disease.
Trump is nothing to clap about.
Juice Box
@Brachiator: Both California and Texas have instituted tort reform. It changed the way malpractice pay outs were structured, but did not in anyway change health care costs. It did change who receives those pay outs. (Hint: not poor people). Most people who are in favor of “tort reform” have no idea what they’re talking about.
Whenever I read a comment with the words “tort reform” or “the AMA makes doctors…”, I stop reading and move on because this person is not arguing from any amount of knowledge.
gene108
@Kylroy:
The ACA was a huge regulatory change.
The timing was also during the worst of the Great Recession, when businesses were wondering “fuck, am I going to survive?” and “now these fuckers in Congress and the White House want me to redo a bunch of HR shit for benefits, if I’m in business 4 years from now?”…”Fuck”…
Now the ACA is the status quo. Changing to something else will be disruptive. And may or may not save a company money.
Edit: There’s a certain amount of inertia built into resisting change and that’s now on the side of keeping the ACA in tact.
Barbara
@Kay: Yep. But it’s also important to remember that the so-called wwc who were most likely to vote for Trump were those on the higher end of the income scale. They are the most insulated from consequences, though not entirely. They could be faced with hospital closures in states due to reduced Medicaid expansion. It’s why a lot of southern states eventually capitulated to expansion. It was becoming increasingly difficult in non-prosperous areas for hospitals to stay afloat. That trend will reassert itself. Rural areas in southern states will be seriously screwed.
hovercraft
@Woodrowfan:
The members of the GOP Doctors Caucus make me doubt their ability to talk about anything within their medical specialty.
Members
Phil Roe, M.D., co-chair
John Fleming, M.D., co-chair
Diane Black, R.N., vice chair
Ralph Abraham, M.D.
Brian Babin, D.D.S.
Dan Benishek, M.D.
Charles Boustany, M.D.
Larry Bucshon, M.D.
Michael C. Burgess, M.D.
Scott DesJarlais, M.D
Renee Ellmers, R.N.
Paul Gosar, D.D.S.
Andy Harris, M.D.
Joe Heck, D.O.
Tim Murphy, Ph.D.
Tom Price, M.D.
Mike Simpson, D.M.D.
Brad Wenstrup, D.P.M.
I don’t see anyone on there I would be comfortable going to see if I had a choice.
Botsplainer, Cryptofascist Tool of the Oppressor Class
@Juice Box:
Tort reform incentives are so very counterintuitive – they work as a transfer tax upon the injured to give to the the providers which injure them, as well as their insurers.
Poopyman
@hovercraft: Glad to see the GOP Doctors Caucus has men as MDs and women as nurses, as God intended.
Botsplainer, Cryptofascist Tool of the Oppressor Class
@Poopyman:
In this climate, we can only hope that Petraeus gets a spot. He’s the least bad of bad alternatives.
Tazj
Tom Price is such a lovely caring person. These were his words in regards to the contraception coverage mandate in Obamacare via a 2012 interview with ThinkProgress.
Pay for your own slutty pills, sluts! Those of you too poor or disabled to properly pay for your healthcare, you should have gotten a better job before you became sick. Hold a fundraiser or a bake sale like the more industrious citizens of our country do.
hovercraft
@Brachiator:
Why do they insist that tax cuts will cure everything that afflicts the economy, no matter what the situations is. In good times cut taxes, in bad times cut taxes, it’s the magic of giving rich people more money, it will cure any and everything that afflicts the economy. Protecting the rich and their money is good, eliminating rules is good, if a company’s product hurts you, tough, their profits must be protected for the share holders, states trying to protect their people must be punished by having their regulations undercut by states that are more interested in protecting their businesses than their people.
Proof is only necessary for liberal policy proposals, the GOP relies on magical things like “dynamic scoring”
D58826
I think Lincoln is going to have to revise the last line of his Gettysburg Address to : ‘government owned by the 1%, for the 1%, and paid for by the 99%’.
hovercraft
@mai naem mobile:
Trump Picks Bush Admin Official Elaine Chao As Transportation Secretary
Vhh
@Fair Economist: Rurals voted Trump, expecting a white supremacist welfare state (see Nazi Germany, 1933). What they are going to get will make Obamacare look like Paradise. Serves them right. Happy to pray for them.
FlipYrWhig
@hovercraft: That’s because what Republicans (say they) believe is letting you keep your own hard-earned money, while what Democrats (are said to) believe is taking your hard-earned money and giving it to some mooching loser. That’s why tax cuts are always the solution and welfare is always the problem. There is no reasoning people out of this. There is only outvoting them. And if the sainted White Working Class doesn’t want to join the proper side, let’s find enough other people from enough other groups that we don’t have to worry about that anymore. As I’ve said before, how about making the REPUBLICAN PARTY the party that stands up for white working class interests? It’d be a damn sight better for the country if the GOP stood for that instead of obscene wealth, hypothetical babies, and cake-baking bigots. It’s not fair to make Democrats stand for all interests and solve all problems while the Republicans just get to plunder and smite.
hovercraft
House Majority Leader: Repeal Obamacare First Then Replace Later
Head desk.
hovercraft
Paul Ryan Lays Out His Top Four Priorities For When Trump Takes Office
But I thought the Shitgibbon was going to clash with the “grown up” agenda of Speaker Ryan.
Vhh
@Fair Economist: Rurals voted Trump, expecting a white supremacist welfare state (see Nazi Germany, 1933). What they are going to get will make Obamacare look like Paradise. Serves them right. Happy to pray for them.@Barbara:
SenyorDave
@hovercraft: My brother is a doctor, and he is fond of saying that someone had to finish in the bottom half of their medical class. He went to a good medical school, Mt. Sinai in NYC, and he once told me that he would not have gone to two-thirds of his graduating class for medical care.
Mayur
@Fair Economist: @Fair Economist: I’ll only say this once and it’s not my true feeling, but a very strong part of me hopes those rural fuckers die. They gave us this bunch of assholes.
Kay
“Everything we said about Clinton’s emails was complete bullshit and we’re sorry we misled the public with all our phony handwringing about national security”
They won though! They got their guy in! Huge tax cuts for all of them! Now watch the “white working class” disappear from discussion completely. We’re back to the real topic of interest- the white upper class.
Kay
@hovercraft:
Because they seek to avoid accountability. They don’t want to be responsible for health care. They’ll get away with it too. They’ll get the political benefit of repealing Obamacare and avoid responsibility for a replacement.
They won’t ask about the replacement anymore than they ask about Trump’s tax returns.
FlipYrWhig
@Kay: See, that’s because Petraeus sent classified information to his paramour, which isn’t particularly dangerous, while Hillary Clinton had a computer whose contents could be seen by the obviously dangerous, um,
NO CARRIER
hovercraft
@FlipYrWhig:
Case in point:
Morons who voted for Republicans now worry they will take away their health care—as promised
By kos
Tuesday Nov 29, 2016 · 11:50 AM EST
FlipYrWhig
@hovercraft: When it happens, Lisa Botner will blame Democrats for taking care of welfare recipients and refugees and illegals (all part of the same phenomenon) instead of hardworking people like her, which, in her mind, is the only reason why there isn’t enough money to solve the nation’s problems, a/k/a The Deficit. This is what all nonwealthy Republicans think all the time about everything.
Poopyman
@hovercraft:
She’ll be quite surprised to find that dying is not hard at all.
Kay
@FlipYrWhig:
It’s because Petraeus is a man. If you doubt me replace “Petraeus” with “Hillary Clinton” in that sentence.
She was held to a higher standard than any MAN in DC. I know it’s uncool to talk about this and media dismissed it out of hand, but in ten years they’re be studying what happened here as the definition of gender bias. They all did it. They’re supposedly so sophisticated and worldly and diverse and urban and yet they held the woman in the race to a much higher standard than any of the men. This is that. Any woman who did what Petraeus did would be unthinkable.
They’re more conventional that the members of the local Rotary Club. I want higher quality elites. We were looking in the wrong direction. Our problem isn’t dumb plebians. Our problem is our elites are low quality-shallow. That’s why they failed.
Anonymous At Work
@Botsplainer, Cryptofascist Tool of the Oppressor Class: Bonk Bonk Bonk. My head on a desk. Bonk Bonk Bonk
FlipYrWhig
@Kay: I feel like it’s more circular than that: it’s less that Hillary Clinton is a woman than that she has a reputation for being cautious and/or shady, so the things that she does are proof that she is cautious and/or shady, which prove that it was right to view her as cautious and/or shady. That’s why it was an “appearance of impropriety” story more than anything else: something like “the way she didn’t realize or didn’t care how [$THING] would look is the real problem!”
David Petraeus doesn’t have a reputation for cautiousness or shadiness, and no one is going to work to give him one. That’s why he can get away with it.
Of course part of the reason why Hillary had such a reputation in the first place was that she was viewed as the ambitious ice-queen of the shady Clinton duumvirate starting in about 1990, which takes us back to gender, so ultimately maybe we’re both saying the same thing.
Bumper
The comment about rural hospitals has me worried. I live in a rural county with limited medical services. The local hospital was restructured a few years back to qualify for more funding because they otherwise would have probably gone under. This is a poor area and they serve a lot of medicaid patients. What does the future hold for hospitals such as ours?
Barbara
@Bumper: Depends on the state. Some states have turned rural hospitals into de facto emergency centers with the capability to try to stabilize and get patients transported to a bigger facility. This is basically the best they can do. It’s not just an issue with hospitals, physicians are also increasingly scarce in rural areas, and many who are there are aging. This is especially true for primary care and general surgery, so it is getting harder and harder to deliver care in rural areas. This is not all the fault of Republican policies, our vaunted Medicare program has had the effect of spiking the proportion of doctors who become specialists because of the way it pays physicians and its rather hands off approach of graduate medical funding (rather than trying to make sure it is spent on programs that are actually needed). Everyone knows both of these things need to change but no one has the political courage to do it except around the margins. In a lot of ways, the damage is done, because there are simply too few primary care physicians and physicians, like a lot of professionals, really want to live in places with good schools and cultural amenities. So, bye bye local doctor for an increasing number of rural counties.
Percysowner
Well, we don’t have to worry about the plan to replace Obamacare House Majority Leader: Repeal Obamacare First Then Replace Later. The plan is to dump the whole thing then pretend it never happened.
rikyrah
@MomSense:
Yes. I really can’t get past this.
Brachiator
@FlipYrWhig:
You just lost one presidential election with this strategy. Maybe you should try something new.
FlipYrWhig
@Brachiator: I’d prefer to try “waiting for the idiots to die off by natural causes,” but that isn’t working either.
ruckus
@StringOnAStick:
SELFISH. The one word which describes ALL conservatives. It is their only real modivator. And it doesn’t matter what they say, at the root of it all is selfishness.
daveNYC
So if Obamacare goes away, I guess that the eventual Democratic plan to replace it will need to be single-payer or a NHS. Not because they’re better, but because nuking the entire insurance industry might make it harder for the Republicans to claw it back.
Like we’re going to have to craft policies that literally can’t be undone, because the Republicans will try and completely roll them back.
Fucking hell.
Barbara
@rikyrah: It’s more likely that people will go bankrupt or resort to self-medication than die. The reality is that a lot of the health care we receive is pretty well useless, but we don’t even try to ration by effectiveness. Rather, some are given a seat at an all you can eat banquet that includes loads of junk food while others stand outside and can be denied even the most essential nutrition. When you don’t have insurance, that’s when you find out what you really need. When my father retired too early for Medicare and had terminal cancer he got just what he needed, and I believe he would have gotten a whole lot more if he had had Medicare. There is no market correction for this that is palatable to people on whom it is actually tried.
Barbara
@daveNYC: Well, my view is that when and if we reach that point there will be a lot less willingness to work with insurance companies. This is likely to be a consequence of repealing the ACA. I don’t know what will happen to the rest of the health care infrastructure that has been built up based on private plans.
Hal
It’s truly amazing how many people weigh in on how terrible the ACA is who do not need insurance via the ACA. Why do they care so damn much? I have a conservative friend who goes on and on about the law just being awful because as he put it once; “People shouldn’t be forced to buy things they don’t want.” I didn’t even bother reminding him of infant car seats, car insurance or bicycle helmets.
He did make a valid point about the ACA being more affordable, but the fix for an anti-government conservative is impossible for them to conceive. The one perplexing thing to me is he’s self employed, but I’m guessing he’s covered under his wife’s policy, so I guess he can be offended on behalf of people who want their insurance and will now lose it. Oh well. When everyone loses their insurance at least he’ll be thrilled.
The Truffle
Curious: what are the hospitals or other healthcare providers going to say about this? The AARP? Heck, wouldn’t insurance companies be hit since they’d lose subscribers?
Wouldn’t these granny-starving tactics ruin the health care system in the US?
StringOnAStick
@The Truffle: The uncertainty flying about right now is no doubt making every high level health care executive wonder how to deal with this particular tail event. With what the idiot from the house republicans is saying (“repeal now, replace later”), the nice, staid world of actuarial assessment is in real danger of being completely upended. They had plenty of time to build their responses to the ACA; now they have 5 weeks to decide how to handle a huge loss in business when all those subsidized and non-subsidized plans are rendered illegal.
Think We The People aren’t capable of hating health insurance companies even more that we do? Wait until people in the middle of treatment get tossed off their plan; it should make for some great tear-jerker TV for the local stations. Or when the rural hospitals that were barely hanging on before ACA go belly up and even the local clinics go away. These stories wont be as profitable as covering every tweet by Rump was during the election, but once the Great Recession II hits thanks to all this disruption, they’ll take what they can get to attract eyeballs.
Obviously the rethugs have been building their voter exclusion machinery for a long time, I just don’t think they expect all the wheels to turn and then spit out Rump. Or maybe they’ve become so radicalized that they give no thought to what all this sudden disruption will do to the economy, because “those people” deserve the righteous, cleansing fire. They are the new Khmer Rouge.
Raven Onthill
Well, if all the health insurance companies go down, the blue states can build their own plans. Romneycare might be the model, and some states might try something else; perhaps some sort of single payer system. I suppose they will pretty much have to. I cannot imagine what will happen in the red states.
Richard Mayhew
@Raven Onthill: Problem with Blue State care Romney care is money — Massachusetts could do it as the Feds picked up a good chunk of the tab.