Five days after the presidential election, I wrote a concession message to Trump voters congratulating them for what they had won. To those Trump promised would get “sick of winning,” I predicted, “You've won his ‘big and beautiful’ Obamacare replacement plan that will take away health insurance from 22 million Americans.” If the president-elect and his GOP allies in Congress got their way, I suggested, “millions of people across America will have the opportunity for financial ruin and even needless death, and maybe both.” And thanks to President Trump, “you could be one of them, especially if you live in a red state like Arkansas or Kentucky where Obamacare had the biggest impact in dramatically reducing the ranks of the uninsured.”
Now that Congressional Republicans are facing a growing backlash as they struggle to pass their ever-changing American Health Care Act, I won’t say I told you so. Instead, I will simply state that events have transpired exactly as I foretold.
As it turned out, Paul Ryan’s hand-picked director of the nonpartisan Congressional Budget Office (CBO) didn’t merely reject the GOP myth that Obamacare was in a “death spiral.” Much to the chagrin of President Trump, House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell, the CBO forecast 24 million Americans would lose health insurance under the GOP plan over the next decade. Premiums would rise for both older and lower-income people. Under the AHCA, deductibles and out-of-pocket costs would invariably jump for all beneficiaries as increasingly inadequate tax credits force the older and sicker out of the market altogether. Adding insult to injury, Trumpcare’s massive cuts to Medicaid spending will be used to fund an $880 billion tax cut windfall for the wealthy. The ultimate irony of the GOP’s supposed replacement for the Affordable Care Act is that Trump voters will disproportionately lose their health coverage while blue state millionaires cash their checks from the United States Treasury.
Of course, that perverse outcome was known long before Republicans first began chanting “repeal and replace” seven years ago this week. That’s because now, as it has been since what became Obamacare was first debated, the defining irony of GOP opposition to it has been this:
Health care is worst where Republicans poll best.
A trip back to 2009 shows why.
As Congress was just beginning to discuss health care reform that spring, Alec MacGillis asked in the Washington Post, “Who will pay for universal health care?” His answer—“blue states more than red”—was obvious:
Those in the red states still smarting over Barack Obama's election victory can perhaps take solace in this: The Democrats' No. 1 domestic policy initiative, universal health care, is likely to help red America at the expense of blue.
Health-care reform may be overdue in a country with 45 million uninsured and soaring medical costs, but it will also represent a substantial wealth transfer from the North and the East to the South and the West. The Northeast and the Midwest have much higher rates of coverage than the rest of the country, led by Massachusetts, where all but 3 percent of residents are insured. The disproportionate share of uninsured is in the South and the West, the result of employment patterns, weak unions and stingy state governments. Texas leads the way, with a quarter of its population uninsured; it would be at the top even without its many illegal immigrants.
A quick glance at what Gallup called the “uninsured belt” showed a striking resemblance to the 2008 electoral map. By 2011, three years before Obamacare’s individual insurance mandate was to finally kick in, Texas far and away led the nation with an uninsured rate of a staggering 28 percent. Led by Mitt Romney's Massachusetts, 9 of the top 10 performing states voted for Barack Obama in 2008.
Before Obamacare, health insurance more or less followed the electoral map.
But merely tallying up the ranks of the uninsured understated the magnitude of the health care horror story then unfolding in Red State America. When the Commonwealth Fund released its 2009 state health care scorecard, which measured each state’s performance in providing health care access, prevention and treatment, avoidable hospital use, equity across income levels, and healthy lives for residents. Again, while nine of the top 10 performing states voted for Barack Obama in 2008, four of the bottom five (including Arkansas, Mississippi, Oklahoma, and Louisiana) and 14 of the last 20 backed John McCain. That at least was an improvement from the 2007 analysis, in which all 10 cellar dwellers had voted for George W. Bush three years earlier. (When then-Texas Gov. Rick Perry co-authored an op-ed with Newt Gingrich in November 2009 titled “Let States Lead the Way,” the Lone Star State was ranked 46th in the country.)
Most of the top-performing states voted for Barack Obama in 2008 and 2012.
The cellar dwellers generally backed John McCain and Mitt Romney.
Sadly, red states didn’t just generally lack the resources of their blue state cousins. Residents of GOP-controlled states also were sicker—often much sicker. In November 2009, a United Health Foundation analysis (funded by UnitedHealth Group) examined “22 indicators of health, including everything from how many children receive recommended vaccinations, to obesity and smoking rates, to cancer deaths.” Echoing the results of that year’s “America’s Health Rankings,” the results were quite familiar. As Forbes explained:
Vermont ranked first this year thanks in part to its low rate of obesity, high number of doctors and a low rate of child poverty. New England in general sets a benchmark for the country, the report found. All six New England states are in the top 10. These states have favorable demographics and an excellent public health infrastructure, including a large number of doctors per capita.
Eight of the 10 bottom-ranked states are from the south, with Mississippi coming in dead last for the ninth consecutive year. Mississippi has a sky-high death rate from heart disease and high infant mortality. In general, residents of these states are more likely to be smokers or to be obese, the report found. They also have worse health insurance coverage, fewer physicians per capita and live in areas with high violent crime and more child poverty.
After the full implementation of the Affordable Care Act, the picture changed dramatically. The percentage of Americans lacking health insurance plunged from 16.0 percent when Obamacare was signed on March 23, 2010 to just 8.6 percent by January 2017. And as I pointed out last fall, that was only the beginning of the ACA’s positive impact:
By most measures, the Affordable Care Act which made health insurance possible for some 25 million Americans has been an overwhelming success. Over 10 million people have purchased private insurance through the Obamacare marketplaces, with about three-quarters receiving subsidies to help cover the cost. States which chose to expand Medicaid have, as predicted, extended coverage to millions more of their residents, slashed their costs for uncompensated care for the uninsured and improved the financial stability of their hospitals. At less than 9 percent, America's uninsured rate is at the lowest level on record. And the ACA hasn't just remained under budget even as the rate of health care cost growth has slowed. Obamacare, it turns out, has helped reduce income inequality.
But that very real progress nationally shouldn’t obscure the dramatic improvements in some of the lowest-performing states. As the Gallup-Healthways Well-Being Index reported in February, six states reduced their uninsured rate by at least 10 percentage points between 2014 and 2016. As they have since the opening of the Obamacare exchanges and the expansion of Medicaid, Arkansas and Kentucky (each of which began with more than 20 percent uninsured), made the greatest progress of all:
After Obamacare, the percentage of uninsured drop by 12 points in Arkansas and Kentucky,
Again, the improvements under the Affordable Care Act weren’t limited to insurance for those age 19 to 64. In its 2015 roundup, the Commonwealth Fund highlighted the major advances in states including Louisiana, Oklahoma, Tennessee, and Kentucky:
While Democratic states continued to lead the rankings, red states made large gains after the ACA.
Its 2017 scorecard (using 2015 data) showed that 14 of the top 15 best performing state health care systems voted for Democrat Hillary Clinton. Only one of the bottom 15 (Nevada) failed to vote for Republican Donald Trump. But in comparing their performance compared to two years earlier, Kentucky and Oklahoma were the most improved across the Commonwealth Fund’s 25 individual indicators. Ten of the 15 most improved states voted for Donald Trump for president in 2016.
Some of the biggest improvements came in the old “uninsured belt” in the old South.
Now, it should be noted that states in which Republicans controlled the governor’s office and the legislature could have done better still. But as widely predicted in 2013 and 2014, Republican obstructionism prevented that from happening. After all, the lawsuit that unsuccessfully challenged the constitutionality of the Obamacare individual mandate also made the law’s Medicaid expansion optional for the states. All 10 states that achieved the greatest reductions in their uninsured rates opted for Medicaid expansion. And as the Commonwealth Fund lamented, the states that refused to do so experienced much smaller declines in the percentage of uninsured adults.
The states that refused to expand Medicaid made a huge mistake.
The GOP’s big “no” to Medicaid expansion in 22 states may well be the greatest act of political spite in modern American history. After all, millions of red states residents weren’t just left without insurance because they needlessly fell into the “coverage gap,” where they earned too much for Medicaid and not enough to qualify for subsidies to buy private insurance. As multiple studies predicted, the opt-out states saw their hospitals struggle and sometimes close, especially in rural areas, while the expansion states enjoyed greater stability as the need for uncompensated care for the uninsured plummeted. Republican states like Missouri, Georgia, and Texas also shot themselves in the foot by banning or limiting the work of so-called Obamacare “navigators.” They hindered that network of non-profits, churches, community groups, universities, and hospitals who help enroll Americans in insurance under the ACA, despite the fact that many of the very same groups perform the same function for Medicare Advantage and the Medicare Part D prescription drug program. The same goes for the Republican sabotage of reinsurance “risk corridors” also used by Medicare programs, the gutting of which helped leave dozens of Obamacare co-ops (including mine in Oregon) insolvent when Uncle Sam paid only 12 cents on the dollar owed to them.
Nevertheless, progress for Republican states and Republican voters thanks to the Affordable Care Act has been very real and very significant. But what President Obama and Democrats in Congress giveth, President Trump and Republican leaders in the House and Senate now want to taketh away.
Even as these words were being written, House Speaker Paul Ryan was working late into the night to come up with a version of his American Health Care Act cruel enough to win over the support of the GOP’s hard-line Freedom Caucus. But while the details of erasing Obamacare’s “essential health benefits” (EHB’s), a Medicaid per capita cap or block grant for the states and perhaps richer tax credits for older enrollees are all still moving targets, there is little doubt that Ryan’s will be a plan of draconian health care rationing. And bearing a surprising brunt of that pain will be those who pulled the lever for Donald Trump on Election Day.
Here’s why.
Ryan’s rationing starts as it always does with subsidies that are too small. Trumpcare’s age-based tax credits start at $2,000 a year for those 18 to 29, and max out at $4,000 for Americans starting at age 60. As the CBO showed, a 64-year old person making $26,500 annually would see their share of his/her insurance premium jump from $1,700 to $14,500 a year. And as the Kaiser Family Foundation showed, the impact of the GOP’s American Health Care Act would be staggering for lower-income and older policyholders compared to the current subsidies provided by Obamacare.
Under the GOP plan endorsed by Ryan and Trump, older and lower income Americans get hit hard.
Under the AHCA, the percentage of uninsured will rise for every age group and income level.
But this picture understates the pain inflicted on current Obamacare beneficiaries. Deductibles and out-of-pocket costs would inevitably rise as well, in part because the GOP plan allows insurers to sell plans which pay out a smaller percentage of costs for physician visits, tests, prescription drugs, surgical procedures, and hospitals. More damaging still, the Ryan/Trump plan eliminates “cost-sharing reductions” provided the Affordable Care Act that currently enable lower income individuals and families to get discounts on deductibles and out-of-pocket maximums. Worst of all, as Kaiser warned, the AHCA’s limits on the growth of its tax credits over time means that gap with the ACA’s subsidies will grow with each passing year:
While ACA tax credits grow as premiums increase over time, the tax credits in the American Health Care Act are indexed to inflation plus 1 percentage point. Based on CBO’s projections of ACA tax credit increases and inflation, the disparity between the average credits under the ACA and the two replacement plans would widen over time. The average tax credit current marketplace enrollees would receive under the American Health Care Act would be 41% lower than under the ACA in 2022 and 44% lower in 2027.
The GOP’s insufficient tax credits become even more inadequate over time.
As many have noted, the GOP’s plan to “repeal and replace” Obamacare will hit Trump voters hardest. It’s no mystery as to why. As the New York Times explained, “The Republican plan offers less assistance to older and lower income Americans, especially in rural areas.” Due to the lack of competition for insurers and health care providers, as the Center on Budget and Policy Priorities (CBPP) documented, 12 of the 15 states hardest hit by the AHCA’s shriveled tax credits are rural ones. Fourteen of the 15 voted for Donald Trump for president in 2016.
The most rural and Trump-supporting states will experience the most pain under the GOP plan.
Trump won almost all of these states. Voters there are among the biggest losers in his health plan.
And as CBPP also explained, Ryancare won’t protect people who benefitted from Medicaid expansion, either. The result of slashing Medicaid funding and turning over what’s left in the form of block grants to the states is knowable: states simply will choose to trim benefits and reduce eligibility, especially during times of economic recession. But the Ryan plan is even worse. As workers’ incomes rise and fall, they may lose Medicaid and then become subject to the 30 percent “continuous coverage penalty” they must pay—not to Uncle Sam, but to a private insurer. In the meantime, those gigantic Medicaid cuts will go to fund tax cuts for millionaires, who just happen to disproportionately live in Clinton country.
While Trump voters will get hit harder in the pocketbook by the GOP health care plan...
...wealthy Clinton supporters will get the lion’s share of the AHCA’s tax cuts.
Worse still, each state’s block grant will have a per capita cap that only grows each year by the consumer price index plus 1 percent. As with the AHCA’s insufficient tax subsidies, that simply won’t keep up with the usually higher rate of medical inflation. The inevitable outcome, the CBO predicted this week, “is 14 million fewer Medicaid enrollees by 2026.”
Now, all of these numbers could still change. After all, as of this writing, House Republicans were preparing to vote on an unfinished revision to the GOP Obamacare “replacement” bill, one the Congressional Budget Office hadn’t yet seen, let alone scored. What, if anything, the Senate votes on remains mysterious, too. But what isn’t a mystery is what will happen if President Trump ultimately affixes his signature to any Republican health care bill. His voters will suffer. And in those reddest of red states, those very places where Republicans poll best, health care will get a lot worse.
Again.
