Health Reform In Trump Era: Big Step Back, Possibilities For Bigger Steps Forward

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The 2016 election turned on racism, xenophobia and anger at the status quo, including the Affordable Care Act (ACA). The law covered about 20 million, and modestly improved access to care. But it didn’t address the health care problems facing most working families, feeding the perception that the Democratic Party had neglected them. Trump seized on the ACA as a symbol of the establishment’s false promises, and has placed repeal at the top of his to do list.

There are many indicators of what Trump has in mind to replace the ACA, but they’re pointing in different directions. We suspect that the likeliest replacement is a meaner (and rebranded) facsimile of the ACA that retains its main structural element — using tax dollars to subsidize private insurance — while imposing new burdens on the poor and sick.

For Republicans, the ACA poses a difficult dilemma. Its model was conceived by Richard Nixon’s henchmen in 1971, celebrated and elaborated by the Heritage Foundation in 1989, and first implemented by Mitt Romney in 2006. Obama’s version, like these earlier ones, called for sliding-scale public subsidies to help low-income individuals purchase private coverage through insurance exchanges, along with a mandate that individuals (and sometimes employers) buy coverage. For the poor, Obama (like Nixon) relied on expanding Medicaid, but almost all of the ACA’s new Medicaid coverage was channeled through private Medicaid-managed-care insurers. And Obama added progressive elements to the Republican formula, e.g. requiring insurers to cover essential benefits (notably contraception and preventive care) and a new “Medicare” tax on some investment income.

Will Republicans reclaim their health care heritage after years spent rabidly attacking its Obamacare variant? Paul Ryan’s recent pronouncements (and the abiding interests of powerful insurance, drug and hospital firms) suggest that they will. Ryan would rebrand the Obamacare premium “subsidies” as “tax credits,” but make them available to anyone who lacks employer-paid coverage, including the wealthy. In essence, he’d shift some of the subsidy money up the income scale and undermine employer-based coverage. He’d maintain (at least for the time being) Obamacare’s boost to Medicaid funding, but let states cut Medicaid coverage and divert the funds to other uses. And he’d hasten the privatization of Medicare, which has already been proceeding apace.

If there’s a brighter side to this dark picture, it’s that Trump and his allies will reclaim ownership of the Nixon/Heritage/Romney/ACA model. This shift seems likely to unmuzzle single-payer supporters who closeted themselves during the ACA era, fearful that calls for more radical reform would fan right-wing attacks. Already Elizabeth Warren, previously reluctant to criticize the ACA, has been liberated: “Let’s be honest: [The ACA’s] not bold. It’s not transformative. … I’m OK taking half a loaf if our message was ‘Here’s half, now let’s go get the rest.’”

A similar strategic perspective motivated PNHP’s founding at a conference of clinicians caring for the poor. After years spent parrying Reagan’s assaults on Medicaid and community clinics, we concluded that a defensive stance was untenable. The U.S. health care system, even with Medicaid intact, prioritized corporate greed over patients’ needs, and was politically indefensible. It wasn’t possible to fix health care for the poor without fixing it for everyone.

That conclusion holds today. For the working class, incomes have stagnated and out-of-pocket costs have soared. For whites without a college education, death rates are rising, driven by diseases of despair like suicide and substance use. Trump spoke (disingenuously) to that despair; Clinton failed to. The resonance of Bernie Sanders’ single-payer message is backed up by polls that show three-fifths of Americans – including a majority of those who want the ACA repealed, and 41 percent of Republicans – favor a “federally funded healthcare program providing insurance for all Americans.”

In health care, reform must address the pressing problems of the majority who have private coverage and Medicare, as well as those who are uninsured or on Medicaid. Only single payer can do that.

A few suggestions for work in the months ahead:

1. Colleagues are, more than ever, receptive to the single-payer message. Let’s talk about it in corridors, conferences, lecture halls and national meetings; use Facebook, Twitter, email and snail mail to recruit new PNHP members; and push journal editors to end their virtual blackout on single payer.

2. With Medicaid under attack, in many states we’ll need to join in its defense. But we must simultaneously declare that this halfway measure is no substitute for real reform. Let’s not repeat the error of ACA backers who tried to convince people that their health care problems had been solved. Similarly, defense of Medicare should not paper over that program’s flaws.

3. We need to help focus the anger at elites onto the real health care elites: insurance and drug firms, and corporate health care providers.

4. In the past PNHP has focused narrowly on single-payer reform, avoiding participation in most broad-based coalitions. We should reconsider that stance in the context of the broad opposition to the Trump regime, and the urgency of threats to our communities. Effective action will require coalitions that span many issues. We should participate in those that include a demand for single payer.

5. It’s time to ramp up organizing for H.R. 676. Politicians can no longer seek refuge in the fiction that health reform is a “done deal” and is working. While work for state-based reforms can provide a useful organizing tool, it cannot address the nation’s most acute health care problems, which are concentrated in states with little hope of local legislation.


  • gardensheila

    Yes! These monsters must be curtailed.

  • Government is about half the health insurance market with Medicare, Medicaid and the VA. This is why the health insurance market is not functioning like a normal market in any other industry.

    Get government out of the health insurance business as much as possible. Limit them to limited regulation and financial support for health insurance to those who need it.

    Obamacare, Medicaid, Medicare and VA hospitals should be phased out. People under these programs and those who are financially below the poverty level should be given a yearly amount that they could use to purchase health insurance.

    Keep the federal regulation stating that insurance companies have to cover pre-existing conditions as long as the person had previous insurance.
    Allow people to purchase insurance from any state. Deregulate state health insurance markets. Unhinge medical insurance from employers in the tax code.

    Getting government out and increasing competition in this way will lower health insurance costs. It cuts the bureaucracy costs, cuts the fraud costs and improves competition and quality of care.

  • DHFabian

    It’s always a problem when today’s media try to write about the poor. The poor won’t see any changes under Trump. We don’t know what lower-income people can expect, but no, ending the ACA will have no impact on today’s poor. Yes, there’s an entire chunk of the population that middle classers don’t even know exist, but the bottom line is that you can’t get money from people who have none. In an emergency, they will use emergency room services as long as that is still available, the same as today. If this ends, they won’t be surprised. We — you and I — are the generation that already stripped them of the most basic human rights of food and shelter. This is just the fate of our surplus population — those not of current use to employers.

  • DHFabian

    Ah, the ghost of Reagan comes back! Trust in the deregulated free market! The more the US embraced this agenda since the 1980s, the more this country has sunk. The overall quality of life in the US went from #1 when Reagan was first elected, taking the first steps to phase out those pesky government programs, down to #48 by the time Obama was elected. Yay, we’re #48!

    For those who don’t brush aside history, we can see that saving this country would have required restoring reasonable regulations and restraints on the voraciously greedy. It would have required imposing heavy disincentives on moving US jobs out of the country. It would have required grasping that world domination by the US is not possible, and getting out of the war business.

    You think we should renew our commitment to the agenda that has pushed the US steadily behind the modern nations in every respect. Especially now, when the US is so close to the tipping point, ready to collapse. Makes perfect sense…

  • DHFabian

    Which monsters? We already let corporate and financial powers off their leashes, and we can now see the end of the US. Maybe it’s time to start hitting back.

  • Big government is owned by the wealthy and paid for by the middle class and poor one way or another. The tax code is manipulated by the wealthy; cost to comply is paid by consumers through higher prices. It increases lobbyists, corrupts politicians and increases difficulty of entry for competition, which causes less employment opportunities for workers and higher prices.

    Excessive regulation increases cost for consumers, decreases job opportunities, corrupts politicians, increases lobbyists and increases difficulty of entry for competition. National debt: $154,000 cost per household paid by the consumer not the rich, through higher prices or lower standard of living. Federal Reserve: low interest loans for wealthy and connected, by the time it reaches lower rungs, rates higher, prices higher, including CEO pay – increasing the inequality gap.

    We have more socialism now than the liberal left’s golden age of the 1950s. We have the FHA, HUD, Freddie Mac and Fannie Mae, Community Reinvestment Act, Social Security, Medicare, Student Loan Programs, Obamacare/ACA, Snap Program, Earned Income Tax Credit, Unemployment Insurance Program and more. So the theory is false and the opposite is true. Socialism hurts the middle class. Big government equals more income inequality, smaller government equals less income inequality.

    The national debt keeps increasing because of deals, aka compromises, between Democrats (social programs and entitlements) and Republicans (corporate welfare and defense). The middle class pays the heaviest burden for the debt; as it goes up, it further increases the inequality gap by lowering their standard of living. National Debt: $19 trillion costs or is financed by each household, who is ultimately responsible for that debt. This comes out to $154,000 per household if paid for in one lump sum. Financed for 15 years at 5% interest it would take a monthly payment of $1218. Do not be fooled each household pays this one way or another, not the rich; whether you pay it directly in taxes and fees, higher prices or by a lower standard of living than you would otherwise have if the government had not spent that money. That is on top of around $26,000 per household for the yearly federal spending. Which is a another $2166 per month. Total $3400 per month per household. The question is: Is your household getting its money’s worth?

    Politicians promise you a fantasy land, that they can make your life golden by decree, raise your pay, give you free education, free health care, paid retirement, cheap housing, easy credit and protect you from the evils of the greedy businessman. In reality they can do nothing of the sort.

    To give you anything they have to take something from you, do not be fooled when they say they will take it from the rich, the rich get it from you (increased prices), in the end it always comes from you. Politicians point at the rich guy as they pick your pocket. They are selling you an illusion that does more harm than good, because in the process they disrupt the free flow and balance of the market causing unintended consequences.

    Politicians that promise to fix your life by taxing the greedy rich to cover the cost are really the sleaziest of middlemen that are selling you pixie dust while they take their cut, which is power.

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