I sure have missed Barack Obama. As much as I’ve come to appreciate the talents and charms of Joe Biden and Kamala Harris, it is great to see the 44th president out there again talking to voters, and even having some fun, for example, slamming Trump’s heretofore unknown Chinese bank account. The “Beijing Barry” line was epic. But when it comes to health care, and the Republican push to overturn the Affordable Care Act in the middle of a pandemic with no plan to replace its protections for people with preexisting conditions, Obama turned serious.
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In Miami on Saturday, President Obama eviscerated the current occupant of the White House and his party on health care, and specifically on what would happen if the Supreme Court does strike down the ACA:
When they’re asked about it, they say, well, look, we’re going to have a great replacement. It’s coming. It’s going to be there in two weeks. It’s been 10 years now. Every two weeks they say they’ve got a replacement and they haven’t come up with [anything]. They’ve never had a replacement. I promise you. I’ve asked. I asked back when I was president. I said, show me your replacement and we can talk. Nothing, nada, zero, zilch, goose egg. The reason they don’t show you their plan to actually provide people protections when it comes to preexisting conditions is because they don’t have one and they never have.
To his credit, Obama’s vice president got off a pretty good zinger of his own on this point during last week’s presidential debate: “He’s never come up with a plan. I guess we’re going to get the preexisting condition plan the same time we [get] the infrastructure plan that we waited for since ’17, ’18, ’19, and 20.”
Jokes aside, let’s make clear what would happen if Amy Coney Barrett and the radical right-wing majority on the Supreme Court disappear Obamacare. At least 21 million people who have gotten health coverage through the law would lose it, including 12 million adults benefitting from the ACA’s expansion of Medicaid, and three million kids who got covered through their parents thanks to that expansion or the law’s expansion of the Children’s Health Insurance Program.
Plus, up to 133 million Americans now suffer from some kind of preexisting condition. The ACA prevents health insurance companies from discriminating against them on price, or simply denying or retroactively cancelling their coverage—two things that were all too common beforehand. According to the Kaiser Family Foundation’s analysis, 27%—more than one out of four—of all adults ages 18-64 has a preexisting condition serious enough that they would find themselves unable to get coverage at any price if not for the ACA. Please note that analysis was done pre-COVID, which has left huge numbers of Americans with a diagnosis that could put them in a similarly dire situation if Obamacare is repealed.
As we know, The Man Who Lost The Popular Vote has no plan—there wasn’t even one in the big fat binder full of malarkey he had press secretary Kayleigh McEnany present to Lesley Stahl of 60 Minutes after he stormed out of their recent interview.
This is just the latest attempt by Trump to fool people with an eye-grabbing visual that has no actual substance when one examines it closely. In many ways, it’s a metaphor for his entire gaslighting presidency. What’s incredible—and I mean this literally, in that I find it impossible to believe—is that two separate polls found that over 80% of Republicans somehow think their candidate will do more to protect people with preexisting conditions than the Biden-Harris ticket.
Trump keeps saying he’ll show us his plan, just like he did in the summer, and in the spring, and in 2019, and long before that.
I’m thinking it must be the same “corner” Trump’s been saying—with the dead-eyed look of a guy selling snake oil cures—we are “rounding” on COVID-19. Most recently, the Orange Julius Caesar repeated the lie about his (nonexistent) healthcare plan to Stahl:
Trump: It is developed, it is fully developed. It's going to be announced very soon--
Stahl: When?
Trump: When we see what happens with Obamacare.
Yeah, I’ll believe that just as much as I believe we’ll see his taxes when the audit is finished. One might ask what Trump hopes to accomplish by pulling stunts like this, given that the media debunks them immediately. The answer is that, as the aforementioned surveys show, there are plenty of people who simply ignore the real media if the impeached president tells them something different. Trump’s campaign strategy—i.e., whatever his gut tells him to do in a given moment—relies on there somehow being enough of these voters to put him over the top. We’ll find out if he’s right in a week.
Regarding the election, this question of where the Republican replacement plan for Obamacare is has also tripped up candidates further down on the ballot. One of the only races where a Democrat is concerned with holding on to a U.S. Senate seat is in Michigan. That’s where Republican John James last week face planted when an interviewer asked about the lack of a replacement plan for the ACA either from Trump or on his own campaign’s website.
Now I want to focus specifically on people with preexisting conditions. As he has before, Trump on 60 Minutes maintained that he would protect them if Obamacare fell—and he said he “hoped” it would fall. Here’s the relevant section of the interview:
They will be “totally protected,” Trump claimed. What he either doesn't know, comprehend, or care about is that he can't protect people with preexisting conditions without a larger national healthcare system that either is the ACA—or something so similar that the difference is meaningless—or something even more progressive like Medicare for All.
Here's why: if Trump tries to just require the insurance companies to sell policies to people with preexisting conditions at the same price as everyone else, even though those folks will almost certainly need more health care, he'll put them out of business. Putting aside how one feels about such a development, it would cause a tremendous disruption to our healthcare system.
The requirement that insurance companies treat people with preexisting conditions the same as everyone else works hand in hand with other elements of Obamacare—or any conceivable national health insurance system. Without being part of that system, such a requirement would mean large numbers of healthy people with enough money to pay out-of-pocket healthcare expenses as long as they didn’t become really sick or injured would simply go uninsured until they became really sick or injured. At that point, those people would buy insurance—paying the same premiums as everyone else—and run up huge medical bills that lead to major losses for the insurance companies.
In order to avoid those losses, the companies would have to ramp up the cost of premiums, which would only drive additional healthier people out of the market, thus driving up premiums even more, and rinse and repeat. The cycle—known as a “death spiral”—would destroy the insurance market completely, as Larry Levitt, the Kaiser Family Foundation’s executive vice president for health policy, explained in a Washington Post op-ed. Regarding the protections for people with preexisting conditions, Levitt’s piece concluded: “You can’t just sprinkle magic pixie dust and wish away the complications and trade-offs—which, so far, is Trump’s approach.”
The only way to require the companies to not discriminate on preexisting conditions without bankrupting them and/or creating the death spiral is to give them something in return. The individual mandate was supposed to get people to buy insurance (and if they didn't, to contribute to the pot anyway), but that's gone. Nevertheless, far more impactful were: 1) the creation of the individual market that allowed millions of people to buy insurance without having to go through an employer, and 2) the subsidies in the ACA that have made insurance premiums affordable for millions who couldn't have afforded it before. Most of the people getting insurance on the exchanges created by Obamacare are receiving subsidies—84% during the most recently completed open enrollment period—so the exchanges without the subsidies would do little good.
Having those millions more customers—all under 65 years old, as seniors citizens get Medicare—means millions of younger, relatively profitable policy-holders who balance out what the companies lose by no longer being able to discriminate against those with preexisting conditions.
There’s also another element the system needs in order to work. The government shouldn’t subsidize the purchase of crap policies—that’s an industry term—that don’t provide adequate coverage. So the ACA included rules to establish baselines of what must be covered in every policy, in order to ensure that the companies don't just get all these new customers on taxpayers' dimes, and then sell them junk insurance, not to mention protecting consumers in general. Note that Trump has actually weakened those safeguards, as the Brookings Institute explained here.
All these pieces complement one another. Protecting people with preexisting conditions requires these other components to make it work for: a) the companies, b) the people who need insurance, and c) the government. That's why you need Obamacare, or something more progressive like Medicare for All. There is simply no other way, despite what Trump pretends.
Furthermore, it’s not just that Trump is lying about protecting people with preexisting conditions if Obamacare is repealed. He’s also been lying when he talks about the things he’s done to protect them thus far, such as when he claimed that he had “saved Pre-Existing Conditions in your Healthcare.” (It’s important you all know that’s his capitalization, not mine.) How exactly? Well, a month ago Trump signed an executive order that he touted with great fanfare because it supposedly protects people with preexisting conditions no matter what happens with Obamacare at the Supreme Court.
Sounds great, doesn’t it? The problem is that, because it is an executive order issued by the president alone rather than actual legislation, it will do as much to accomplish what it claims to accomplish as the email I sent to Ralph, my second cousin once removed, in which I too declared protections for people with preexisting conditions. In fact, the very people Trump has appointed to leading administration positions in health care admitted as much in a press briefing. Ah, what a joy it must be to serve in that administration.
The reality of Trump’s record is somewhat different from the grandiose claims he’s made, as Margot Sanger-Katz laid out in the New York Times. Her article included this remark from someone who will never be confused with a progressive on health care:
“If there’s any merit in the president’s record on pre-existing conditions, it is purely by accident,” said Michael Cannon, the director of health care policy studies at the libertarian Cato Institution. Mr. Cannon, who favors a less regulated health insurance market, is no fan of Obamacare, but says that Mr. Trump has little to support his claims.
Health care consistently ranks as one of the most important issues for American voters as we head into the final week of this election, and not only because we are in the middle of a pandemic. Joe Biden has pledged his support for strengthening Obamacare by making a public option available to all. He’ll also reform the law so that working- and middle-class families who are just above the current income cutoffs will be able to receive premium subsidies. Biden will reduce the maximum cost of premiums purchased on the Obamacare exchanges from 9.86% of household income to 8.5%, saving significant money for large numbers of Americans. He’ll also provide the Obamacare subsidies to people who would’ve received Medicaid if their states had accepted the ACA’s expansion of that program, so that they will get coverage without having to pay a dollar in premiums.
What’s Donald Trump’s plan? Apparently it’s to get rid of Obamacare, and the protections it provides to tens of millions of people with preexisting conditions, while lying about having a way to protect them without the law.
Conservatives love to talk about having healthcare choices. Judging the plans of the two major candidates, it shouldn’t be a difficult choice at all.
Ian Reifowitz is the author of The Tribalization of Politics: How Rush Limbaugh's Race-Baiting Rhetoric on the Obama Presidency Paved the Way for Trump (Foreword by Markos Moulitsas)