GOP's leaked 'repeal and replace' plan is the scorpion striking the frog
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Senate Democratic leader Charles SchumerCharles (Chuck) Ellis SchumerOvernight Health Care: Schumer calls for tying ObamaCare fix to children's health insurance | Puerto Rico's water woes worsen | Dems plead for nursing home residents' right to sue Crying on TV doesn't qualify Kimmel to set nation's gun agenda Trump knocks ‘fake’ news coverage of his trip to Puerto Rico MORE compares Republicans confounded over Obamacare to “the dog that caught the bus.”  But now that President Trump and House Republicans have settled on the broad outlines of a scheme to “Repeal and Replace,” the better parable is the frog and the scorpion.

The scorpion, you may recall, asks the frog to carry him across a stream.  The frog demurs, asking, “how do I know you won’t sting me?”  The scorpion offers reassurance: “If I do, I’ll die too.”  Persuaded, the frog sets forth, scorpion on his back.  Then, midstream, the scorpion stings.  The dying frog asks, “why?”  The drowning scorpion replies, “it’s my nature.”

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President Trump, promising health care for all, was carried to office in part by Americans alarmed over rising premiums, copayments, and deductibles.  But the “Repeal and Replace” scheme he’s signed onto is an assault on the ability of both markets and government to deliver decent care to millions who voted for him.  And it would radically remake American medicine into a caste system, with levels of care openly tied to wealth.

 

The plan, announced jointly two weeks ago by House Speaker Paul RyanPaul RyanThe Hill Interview: Budget Chair Black sticks around for now Gun proposal picks up GOP support GOP lawmaker Tim Murphy to retire at end of term MORE and Secretary of Health and Human Services Tom Price (who assured his former House colleagues that Trump “is all in”), deals a devastating blow to the individual insurance market by getting rid of the Affordable Care Act’s sliding-scale, income-based subsidies.  

In their place, the plan introduces a tax credit that varies with age, not income, putting more-than-skeletal coverage out of reach for millions.

The Ryan-Price proposal lacked numbers, making precise coverage projections impossible.  But a House Republican bill leaked last Friday, labeled a “Discussion Draft,” calls for tax credits that vary with age by only a factor of two, while allowing premiums to rise with age by a factor of five.  

The upshot: A scorpion’s sting for older, lower- and middle-income Americans (Trump’s core supporters) who can today afford mainstream individual coverage thanks to the ACA’s subsidies.

Worse, the Ryan-Price scheme would cause these consumers’ out-of-pocket medical costs to soar, in brazen breach of Trump’s pledge to bring co-payments and deductibles down.  

Ryan-Price replaces the ACA’s income-based assistance program for co-payments and deductibles with a reverse-Robin-Hood gambit (and gift to the financial-services industry) — expanded tax-exempt savings accounts for health expenses.  They’re valuable in proportion to people’s marginal tax rates (and thus their incomes), so those most in need of help with the bills insurance won’t pay benefit least.

Plus there’s a cascade effect.  Lower-income Americans unable to manage this greater out-of-pocket burden will miss out on early diagnosis and make less use of care their insurance does cover.  They’ll not only suffer adverse health consequences; they’ll cross-subsidize (through their premiums) covered services for those better able to afford co-payments and deductibles.

More brutally, Ryan-Price would end Medicaid as a pathway to first-world care for the 62 million Americans (20 percent of our population) it covers.  Not only would Ryan-Price slash the ACA’s 90 percent federal subsidy for Medicaid expansion (forcing states to choose between huge tax hikes, skeletal coverage, and rolling back the expansion); it’d cap federal spending on Medicaid by paying each state a either a fixed amount per enrollee or a set amount overall.

The cap sounds like a sensible move toward medical cost control, but it’s not.  Market forces drive health spending for the nearly 180 million Americans with private coverage.  Uncapped statutory formulae determine spending for Medicare’s 43 million beneficiaries.  Within these constraints, doctors who treat privately-insured and Medicare patients judge medical need.  Standards of care evolve and costs increase as doctors adopt new tests and treatments.

The Ryan-Price Medicaid caps won’t rein this in.  They apply to less than a quarter of America’s 280 million insureds.  They hold health spending for the poor selectively in check while clinical standards and costs rise for everyone else.

Instead of health care for all, the Ryan-Price “Repeal and Replace” blueprint reimagines medicine as a steeply-tiered system of clinical standards, therapeutic outcomes, and financial risk.  

The growing ranks of America’s low-income uninsured endure at the bottom.  Medicaid recipients, unable to afford first-world care absent cross-subsidies to doctors and hospitals from better-paying patients, sit at the next level.  

Lower-income Americans with paltry private coverage and crushing out-of-pocket obligations occupy tiers above, topped by Medicare beneficiaries, then the fortunate few with generous private insurance and incomes high enough to benefit substantially from tax-free health savings accounts.

Expect socio-economic disparities in care to widen.  Count on more of us losing our loved ones to illnesses that earlier intervention can control, even cure.  Figure on rising rates of medical bankruptcy, the tip of the iceberg of sickness-induced economic distress.

These hardships will sting President Trump’s older, lower-income base disproportionately.  “Bad hombres” and the wall Mexico will pay for may work as distractions for now but these misdirection plays won’t shield Trump politically as Americans who live on the financial edge begin to experience the cruelties of the health system he’s teaming up with Congressional Republicans to create.  

Unlike the frog, these Americans can deliver payback — when they next vote.

M. Gregg Bloche, M.D., J.D., @greggbloche, is professor of law at Georgetown University and author of “The Hippocratic Myth.”  He helped to develop President Obama’s 2008 campaign health care reform plan and advised the 2008-2009 presidential transition.


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