As the blizzard of political television ads becomes ever more annoying–and less informative–one thing about them has become very interesting. Even Republicans who have previously made it clear that they don’t want government involved in healthcare are airing advertisements touting support for Medicare and willingness to protect pre-existing conditions.
I’ve been particularly struck by the U Turn in Indiana’s Fifth District, where a radically-reactionary, pro-Trump Republican noted for opposing “socialism” (which she has defined to include pretty much anything done by government) has begun running commercials supportive of Medicare and coverage of pre-existing conditions. Evidently, her polling has overcome her previously expressed belief that government should have no role in health care.
She’s not alone.
When the Affordable Care Act (aka Obamacare) passed, several Republicans went on record with their concern that its trajectory would mirror that of Medicare and Medicaid: despite initial resistance, the public would come to expect/demand/approve of the program. Survey research has confirmed those fears, which is why GOP officeholders continue to pretend that they will protect access to healthcare at the same time as they are feverishly working to eviscerate it.
The Brookings Institution recently published a report detailing six ways Trump has sabotaged the ACA.The report began by stressing that its authors did not use the term “sabotage” lightly.
For analytic purposes, the term “sabotage,” should not be used lightly. Presidents upon taking office typically have priorities that trigger executive actions strengthening some programs while weakening others. The losing programs often face resource reductions, pressure to deemphasize certain goals, directives to alter their administrative approaches, and other measures that can undermine their effectiveness. In doing so, a president often pays lip service to the program, claiming it has been “modernized” or otherwise improved. In contrast, Webster’s defines “sabotage” as efforts to foster “destruction and obstruction” and to “cause the failure of something.” In the context of the administrative presidency, it reflects a commitment to program emasculation and termination through executive action. As such, it sharply departs from the constitutional requirement that the president “take care that the laws be faithfully executed.”
There were six actions detailed in the report.
1) The administration dramatically reduced outreach about, and opportunities for enrollment in, the ACA’s insurance exchanges. The administration sharply reduced support for advertising and exchange navigators and reduced the annual enrollment period to about half the number of days.
2) Together with Congressional Republicans, it reneged on commitments to private insurance companies. Those insurers had been offered various subsidies that reduced the risks of participating in the exchanges. The GOP failed to honor those commitments.
3) The administration has constructed what the report calls “off-ramps to cheaper, lower-quality insurance.” One goal of the ACA was to improve the quality of health insurance by specifying essential benefits, guaranteeing coverage of those with preexisting conditions at reasonable rates, and prohibiting insurers from imposing certain spending caps. The Trump administration expanded access to coverage that was cheaper because it didn’t meet these standards and that siphoned off the healthier enrollees whose participation is needed to make the ACA work.
4) It allowed–indeed, promoted– a variety of state waivers that decreased ACA enrollments and undermined its regulatory structure.
5) It discouraged legal “aliens” from enrolling in Medicaid. In a particularly evil move, Homeland Security promulgated a “public charge” rule authorizing officials to treat Medicaid enrollment as a negative factor when reviewing the requests of legal non-citizens to extend their stays or change their status (e.g., from temporary to permanent resident).
6) And then there’s the existential threat. The Trump Administration brought the lawsuit that is now pending at the Supreme Court, attacking the constitutionality of the ACA. If that suit is successful–despite a legal argument that has been widely characterized as ridiculous, despite its endorsement by an appellate court composed of Trump-appointed judges– millions of Americans will lose access to health care.
As a student once reminded me, the United States doesn’t have a health-care system; we have a health-care industry. As a result, millions of Americans remain underinsured or completely uninsured, other millions are bankrupted each year by medical costs, and our health outcomes are among the absolute worst in the developed world.
Deeply dishonest political rhetoric to the contrary, the current Republican Party wants to keep it that way.