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‘We’re gonna come up with a new plan that’s going to be better health care for more people at a lesser cost’ – Donald J. Trump, 1/25/17

The long-awaited Congressional Budget Office report on TrumpCare was released Monday afternoon, and it was every bit as exciting as anticipated, with the excellent news that repeal of the Affordable Care Act would reduce the federal budget deficit by $337 billion by 2026. Isn’t that wonderful? Oh, and it would also result in 24 million people losing health insurance by that time, as well, most of them lower-income and older Americans. There’s that, too. But don’t worry — the Trump administration is absolutely sure the CBO is wrong, and when has Donald Trump ever lied to us about healthcare? Apart from every goddamned time he said his “terrific” plan to replace Obamacare (which he didn’t actually have) would insure more people for less money. Let’s jump into the gory details!

Which Losers Will Lose Coverage And Why

In 2018, the very first year under TrumpCare, 14 million people would go without insurance, largely because once the ACA’s individual mandate and tax penalty for not being insured are repealed, many people would decide they’d rather take their chances than pay for insurance. This doesn’t mean they won’t get sick or have accidents, but the CBO report doesn’t attempt to estimate how many of these newly uninsured will end up having health care costs that the rest of us will pick up through ER visits and so on. So there’s 14 million uninsured, in a congressional election year, but hey, they were exercising their free choice to go without, so hooray for freedom!

Starting in 2020, the rollback of the ACA’s Medicaid expansion, along with the conversion of Medicaid funding to limited block grants to the states, will result in a total of about 24 million people without insurance by 2026, so we should be almost exactly back at the uninsured rate before the ACA. Want a fun comparison? Vox notes, “24 million people is close to the entire population of Australia.” Australia, like every other sane industrial democracy, has universal coverage.

The changes in how Medicaid is funded will even result in loss of healthcare to people who would have qualified for Medicaid before the ACA. So poor people, especially kids and people with disabilities, will be super-extra screwed, which ought to bring a smile to the face of many a good Christian soul who can then feel virtuous after dropping a dollar in the Salvation Army kettle. Quoth the CBO:

Some decline in spending and enrollment would begin immediately, but most of the changes would begin in 2020, when the legislation would terminate the enhanced federal matching rate for new enrollees under the ACA’s expansion of Medicaid and would place a per capita-based cap on the federal government’s payments to states for medical assistance provided through Medicaid. By 2026, Medicaid spending would be about 25 percent less than what CBO projects under current law.

Also, the report predicts a number of states that have only recently expanded Medicaid under the ACA will drop the expansion even before 2020 since they just weren’t into it anyway, although the CBO couldn’t predict which particular states would do that.

Which Losers Will Pay More, And Which Lucky Duckies Will Pay Less

TrumpDon’tGiveAShitCare will look like a bargain to folks who are young and already healthy, since they can drop their insurance without a tax penalty. Ah, but won’t the 30% premium increase for those who go uninsured for over two months keep them in the system? For some, yes — but plenty will also decide it makes sense to pay more for insurance later and take their chances for now. The loss of younger, healthier enrollees will cause premiums for individual plans to increase after 2017 for the older, less healthy people who remain in the pool, which is only fair because they decided to keep getting older and sicker, like a bunch of idiots. However, since there will still be tax credits — much reduced — to subsidize individual plans, the CBO also projects that “a significant number of relatively healthy people would still purchase insurance in the nongroup market.” So it wouldn’t cause a death spiral in the insurance market, just costlier, crappier coverage.

The real losers, as everyone (except congressional Republicans) said from the start, will be older, sicker Americans, especially once insurance companies are allowed to charge older policyholders up to five times as much as younger ones. Also, the maximum tax credit to offset premium costs will now be just $4000 a year. The ACA limits the cost of policies for older people to three times as much, and provides income-based subsidies to offset even those increased costs. Result: Older, less well-off folks will be screwed, hard, as Vox explains:

CBO expects that a 64-year-old who earns $20,000 would see her premiums rise from $1,700 to $14,600 under the Republican plan — a 758 percent increase. She’d be expected to spend more than half her annual income on health insurance.

Sucks to be you, grandma! Yes, let’s bring out that ad about Paul Ryan throwing grandma off a cliff again. Roll 212!

Oh, and those lucky younger folks who’ll be able to buy cheaper health insurance? After repeal of the ACA’s requirement that insurance cover at least 60% of health benefits, the portion of total costs the plan pays — the “actuarial value” of insurance — can drop significantly, resulting in less expensive insurance that covers far less of policyholders’ actual healthcare costs. It won’t quite be the full return of those “junk insurance” plans that cost little and covered almost nothing, since even TrumpDoesn’tCareIfYouDieCare mandates coverage of some basic health services, but it will be similar.

For the lucky ducky younger folks, that means big savings on monthly premiums, but higher out-of-pocket costs if they do need services. Which they won’t, because they intend to stay young and healthy forever, will never have babies, and will definitely not be in car accidents. CBO predicts many insurers will sell mostly plans with much lower actuarial value, resulting in higher costs for plans that do offer better coverage — which are also likely to be less attractive to insurers, since there will be less profit in them. Those low-cost/low-coverage plans will at least keep a fairly large number of younger people in the market, though not enough to keep premiums from going way up for people who want or need better coverage.

And here’s a fun detail: The repeal of the employer mandate may cause quite a few employers to drop coverage for their employees, dumping them into the individual market, where those folks will either go without insurance or buy cheaper, crappier plans. However, notes the CBO — in what seems like a rare overt dig at the slapdash Republican “reform” process — “Some employers would probably delay making decisions because of uncertainty about the viability of and regulations for the nongroup market and about implementation of the new law.”

Oh, yes, and how about defunding Planned Parenthood — any losers there? YOU BET!

The people most likely to experience reduced access to care would probably reside in areas without other health care clinics or medical practitioners who serve low-income populations. CBO projects that about 15 percent of those people would lose access to care.

Eh, fuck ’em, any slut who’d go to baby killers for health services doesn’t deserve healthcare anyway.

At Least The Rich Will Get Richer

The rollback of the ACA’s various taxes would at least provide some help for America’s suffering wealthy folks, who’d get a ginormous tax cut — the best numbers here come from another study released Monday by the nonpartisan Tax Policy Center, which estimated that the vast majority of the tax benefit from ACA repeal would go to the wealthy, according to Howard Gleckman, a senior fellow at the think tank:

The effects are really very dramatic. We found that a typical middle-income family would get a tax cut averaging about $300, while people in the top 0.1 percent would get a tax cut of about $207,000[.]

The group estimates that around 60 percent of the tax savings would benefit people with incomes over $1 million. So that’s nice. And here’s a fun bit of symmetry noticed by Jason Furman of the Peterson Institute for International Economics:

Let’s see, now, what did our great president say about his great replacement for the terrible ACA?

We’re going to have insurance for everybody. There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.

Clearly, everyone else must be lying.

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[CBO report / NYT / Vox / Hullabaloo / Reuters]

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