It’s a new
year. 2017 ended with the GOP passing a landmark tax bill that will provide
huge long-term windfalls to corporations and the very, very rich, but little
and time-limited benefit most folks. “Most”, in this case, being the vast
majority. The “99%” probably underestimates it. Hey, how about I give you $10
once and you support my getting $1,000 a year in perpetuity? Well, why not? At
least I get my $10. Except, whoops, you’ve raised prices on me by $20 a year.
The
Republicans just missed out on their repeal of the Affordable Care Act in 2017,
but there is a strong possibility they’ll try again in 2018. The decision will
certainly be made on political grounds; maybe they’ll want to do it while they
have a one-vote majority in the Senate if they think they might lose it. On the
other hand, maybe doing it will increase the likelihood of them losing even
more Senate seats. Tough one; you know the American people will stand for a lot
of screwing-over, but it may be possible for you to push it too far.
In the meantime, however, the
Trumpenik administration has slashed subsidies for people getting coverage on
the federal exchanges. The President himself tweeted on December 26, 2017 that
the “Tax Cut Bill…essentially Repeals (over time) ObamaCare”. It didn’t, but it
did make it much more difficult for many Americans to obtain health insurance, and
most of them are in states that voted for Trump and the GOP. As CBS reported on the same day, 80% of the 8.8 million newly
covered are in these states. The four states with the highest enrollment,
totaling 3.9 million, were Florida, Texas, North Carolina and Georgia. While
these are states all went for Trump in 2016, all but Texas are in danger of
going Democratic in the future. Florida has long been a swing state (remember
the hanging chads of 2000!), NC is probably flippable in a presidential
election (although, barring a court ruling overturning it, amazing gerrymandering will protect Republican House seats
there), and Georgia is changing quickly. Of the 11 states with the biggest
increases in enrollment, 8 voted Republican (Iowa, Kansas, Kentucky, Missouri,
Nebraska, North Dakota, South Dakota and Wyoming). So cutting subsidies for
buying insurance on the exchanges is a great way to punish your base.
There is
even a school of thought that believes the cutbacks in funding for purchase of
private insurance, along with the dramatic expansion of Medicaid (in the states
that have done so), creates the opposite of GOP intentions, a more
publicly-funded health insurance system. This topic is addressed in the NY Times article “Years of Attack Leave Obamacare a
More Government-Focused Health Law” by Robert Pear, also on December 26. While only about 10
million have gotten coverage by private insurers through the exchanges, and
this will drop as both the individual mandate and subsidies are eliminated,
over 75 million people have benefited from Medicaid expansion. The “Medicare
for All” movement advocated by Sen. Bernie Sanders is gaining increased momentum
in many states (for example, Maine, where it may be pushed over the resistance
of the Republican governor), as people increasingly realize that this is their
only protection. Eliminating the mandate means healthy people will not buy
insurance that they can no longer afford without subsidies, so that the cost of
insurance for sick people will become truly unaffordable. If they do not
qualify for Medicaid, they will be plumb out of luck, unless Medicare is
expanded to cover everyone.
Some
advocate for gradual expansion of Medicare, rather than going straight for
Medicare for All, by extending it to those over 50 or 55 first. This is most
often heard from “mainstream” (“centrist”) Democrats (the Republicans care
about the health of the American people not at all), who have been most remarkable
for their tentativeness and cautious incrementalism when in power, as opposed
to the Republicans’ aggressiveness. And, while expanding Medicare to cover
everyone is the simplest and most straightforward route to a single-payer
insurance system, it must be an “improved and expanded” Medicare for all, as
advocated and detailed by groups such as Physicians for a National Health
Program (PNHP).
Without this improvement people may legitimately fear an underfunded health
system that requires major out-of-pocket expenses, that restricts access to
certain procedures and specialties even when medically indicated, and that is
more focused on cost-cutting than on health care.
Incremental
efforts, such as gradually ratcheting down the age of Medicare eligibility, may
seem to be tactically good ideas, but in fact they are silly and likely to cost
more both in dollars and in worse health outcomes. Medicare, despite its
limitations in funding, has made a phenomenal difference in the health of those
eligible since its introduction in 1965. Those who receive Medicare now, the
aged, blind and disabled, are the population with the greatest health care
needs and costs. However, as physicians we regularly see those just under the
age of 65 but with chronic illness suffering serious health outcomes and costs
until they become eligible. While lowering the age to, say, 55 would enroll
many of those with greatest need, there would always be people with need just
below the age cutoff. More important, as the age of eligibility goes down, the
marginal cost per covered life also goes down, because younger people are
healthier. What makes sense is to simply wrap everyone together, getting both
the benefit of an overall healthier younger population paying in and using
little care and not excluding individuals of any age who (from chronic or acute
illness or accident) do need care.
The day
after all these appeared, December 27, a British physician named Rachel Clarke (@doctor_oxford),
author of the current [British] Sunday
Times bestseller “Your Life in My Hands”, posted a note on Twitter about
her father dying of cancer after a long illness. “One major surgery,” she
wrote, “countless chemotherapies, & a small army of community and
palliative nurses so that he could be at home with us.” She continued: “The bill? £zero. Grief, pain, emptiness – but not bankruptcy. Thank you,
#NHS.” How many of us could say the same
in the US? Some, perhaps many, of us; those with money and good insurance,
which is becoming increasingly rare. But MOST of us could not.
The lives of
all of us, the health of all of us, and the commitment of society and
government to the health of all of us, is what is at issue here. The Republican
Party and its leader have demonstrated their clear and persistent opposition to
it. And it is all of us, including their voters, who are suffering and will continue
to suffer for it.
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