By now, you’ve like already read a slew of analyses and summaries of what is contained in the draft House Republicans’ American Health Care Act (AHCA). The top line points are well-known by now. They leave in place much of the Medicare reforms set forth in the Affordable Care Act (ACA), so much of the work in delivery system reform, at least for now, will continue. Several ACA provisions are also left untouched, including coverage for kids up to 26 on their parents’ plan, coverage for pre-existing conditions, essential health benefits, a cap on out-of-pocket expenditures, and provisions removing caps on lifetime annual benefits. The major changes contemplated are reserved for Medicaid, the health insurance program for the poor. House Republicans propose to gut Medicaid in order to glean $560 million that would serve as tax cuts for the rich. They halt federal support of expansion after 2020, essentially freezing enrollment into Medicaid for the people who would be covered at 138 percent federal poverty level. They also block grant Medicaid payments to states.
The nonpartisan Congressional Budget Office has estimated that 14 million people will lose their health insurance next year, 21 million by 2020, and 24 million in the next 10 years if the provisions in the AHCA are adopted. And for that devastating impact on coverage, we save a paltry $337 billion over 10 years. When the law under consideration contemplates how many millions of people will have their health insurance rescinded, or prevented from getting it altogether, it is worth asking, how did we get here?
Defending and explaining the ACA has taken outsized energy and resources for all those involved—from the time and energy lawyers have spent on myriad policy issues and endless court cases, to the many policy analysts and economists who are asked to provide data, run analyses, explain options, and then provide more data. And these are just folks in the government. The main tactic used to defend the ACA involves the use of data and facts to describe its impact by several organizations such as Brookings, Urban Institute, Center on Budget and Policy Priorities, and the many government and contractor reports from the Department of Health & Human Services and its contractors.
This difficulty of convincing Americans of the benefit of the law existed despite the many credible analyses that abounded showing the great impact the ACA was having. These included, for one, the indisputable fact that 20 million people currently have health insurance who did not have it before. We also know that once people became insured they went to see a doctor, and that, for many, that doctor’s visit was the first in decades. Since it had often been a while, they did incur costs from those first visits, including the cost of medications to treat any previously undiagnosed medical conditions. Without implementation of the ACA (aka Obamacare), though, these individuals would, no doubt, have experienced a far worse sequence of events. The person would not have had insurance, would not have sought care or seen a doctor until it became absolutely critical, and they would likely have ended up in the emergency room, which is the least desirable place to go when a new health issue emerges.
There are no new facts to throw at health-care policy at the moment that we haven’t already heard. What we need to focus on isn’t numbers, but on our moral obligation as a country. Regardless of who pays for health, we must craft health-care policies that don’t leave the very real patients out of the equation. Access to health care is a human need, not just a statistics exercise—and it is time we start taking politicians to account when they fail to treat it as one. Any political decisions we make about health do not stay in the realm of politics; people’s lives are at stake. Take Medicaid, for example: 31 states, along with DC, expanded the program; the 11 million people who are now covered as a result could lose their coverage if the AHCA is passed and signed into law. The Medicaid expansion population, usually those individuals who make about $12,000 annually (or $25,000 for a family of four), would be left essentially to their own devices to find and pay for health care. This level of poverty does not usually permit enough economic flexibility to contribute massive amounts of money to health savings accounts, as Paul Ryan would have these people do. Limited tax credits that would completely help offset the costs of health insurance premiums are not the solution either, and we should not pretend otherwise. So, this brings us back to where we began.
If we are interested in reforming the ACA in positive ways, there are several proposals that have already been made. President Obama has outlined a number of them already in his article in The Journal of the American Medical Association. If we want to make specific changes to Medicaid, well, many states have already begun to streamline and manage their Medicaid programs and tailor specific interventions to better meet the needs of many of their residents. We should help states shore up their programs and continue to innovate, but we could do even more. For example, we could help states pool their resources and purchase clout to negotiate better drug prices for their enrollees; a better handle on the ever-increasing prices of drugs is a sure way to help states reign in their Medicaid budgets. The very real ways in which the ACA could be improved are indisputable, but the Republicans were never likely to engage with any of these ideas. Indeed, their recent proposal has only elucidated the unfortunate fact that, for some, health care simply is not about people.