Ryan, Pence And Price Have A Problem: Even Republicans Want Health Care

Yesterday, Greg Sargent started the news cycle rolling at the Washington Post with a simple question: Will Donald Trump really go through with all of it?. Like many of us, Sargent is rightfully worried that Trump, Pence, Ryan and McConnell "may soon be going forward with an agenda that could inflict radical, disruptive change on millions of people," especially in regard to gutting the Affordable Care Act and destroying Medicare. "We don’t know," he wrote, "how far Trump will actually go. It’s also true that Republicans are taking steps to mitigate the short-term impact of some of the changes being mulled, and are struggling internally with the details in ways that suggest their best laid plans could conceivably go bust. But is there any particular reason not to anticipate the worst at this point?"

Los Angeles Congressman Ted Lieu is thinking along similar lines but he focused on another GOP threat to healthcare-- V.A. privatization. "As the Member of Congress representing the nation’s largest VA hospital," Lieu told the media, "I oppose any effort to privatize VA healthcare.  My opposition to privatization is guided by the voices of veterans and advocates in my district, who understand that we can improve service delivery to our veterans without tearing the VA down brick by brick.  On average, our veteran population is older and sicker than the rest of America-- they have earned and deserve a world-class healthcare system designed to meet their unique needs. Finally, as a veteran myself who served on active duty, I humbly believe that a veteran should be at the helm of the VA.  Our nation’s warriors deserve a leader with a profound understanding of their service and sacrifice.  They deserve a leader dedicated to guaranteeing timely access to the highest quality care."

A poll taken between Nov 15 and 21 by the the nonpartisan Kaiser Family Foundation found that only 1 in 4 Americans want the Republicans to repeal Obamacare. 52% of Republicans would like that to happen, significantly less than the 69% would said they wanted that to happened before the election, but majorities across party lines support many Obamacare provisions-- though not the mandate-- which basically pays for the goodies they all want. This is what the vast majority of Democrats, Republicans and Independents all support from the Affordable Care Act:

• allowing young adults to stay on a parent's insurance until age 26.
• no copayments for many preventive services.
• closing the Medicare prescription drug coverage gap known as the "doughnut hole."
• financial help for low- and moderate-income people to pay their insurance premiums.
• a state option to expand Medicaid to cover more low-income adults.
• barring insurance companies from denying coverage because of a person's medical history.
• increased Medicare payroll taxes for upper-income earners.

Some Republicans are getting nervous about moving from demagoguery to actually taking away people's-- voters'-- healthcare. But not all. Ryan, Pence and Tom Price are all willing to set themselves aflame on a pyre that burns up Obamacare, Medicare, Medicaid and Social Security if it comes to that. Trump... perhaps not so much-- not that anyone knows what Trump thinks about any policies. In his column yesterday, Paul Krugman asserted that Trump is about to betray the white working class voters in Ohio, Michigan, Indiana, Wisconsin and Pennsylvania who made him the electoral college winner.

The evidence of that coming betrayal is obvious in the choice of an array of pro-corporate, anti-labor figures for key positions. In particular, the most important story of the week-- seriously, people, stop focusing on Trump Twitter-- was the selection of Tom Price, an ardent opponent of Obamacare and advocate of Medicare privatization, as secretary of health and human services. This choice probably means that the Affordable Care Act is doomed-- and Mr. Trump’s most enthusiastic supporters will be among the biggest losers.

The first thing you need to understand here is that Republican talk of “repeal and replace” has always been a fraud. The G.O.P. has spent six years claiming that it will come up with a replacement for Obamacare any day now; the reason it hasn’t delivered is that it can’t.

Obamacare looks the way it does because it has to: You can’t cover Americans with pre-existing conditions without requiring healthy people to sign up, and you can’t do that without subsidies to make insurance affordable.

Any replacement will either look a lot like Obamacare, or take insurance away from millions who desperately need it.

What the choice of Mr. Price suggests is that the Trump administration is, in fact, ready to see millions lose insurance. And many of those losers will be Trump supporters.

You can see why by looking at Census data from 2013 to 2015, which show the impact of the full implementation of Obamacare. Over that period, the number of uninsured Americans dropped by 13 million; whites without a college degree, who voted Trump by around two to one, accounted for about eight million of that decline. So we’re probably looking at more than five million Trump supporters, many of whom have chronic health problems and recently got health insurance for the first time, who just voted to make their lives nastier, more brutish, and shorter.

Why did they do it? They may not have realized that their coverage was at stake-- over the course of the campaign, the news media barely covered policy at all. Or they may have believed Mr. Trump’s assurances that he would replace Obamacare with something great.

Either way, they’re about to receive a rude awakening, which will get even worse once Republicans push ahead with their plans to end Medicare as we know it, which seem to be on even though the president-elect had promised specifically that he would do no such thing.

As Krugman pointed out, during the campaign, Trump solemnly swore to not cut Medicare (and reassured his fans that he would replace Obamacare with something "great." So how did Pence talk him into an extremist crackpot like Tom Price as Health Secretary?

TalkingPointsMemo provided a handy reminder and roadmap to Ryan's plans to assault and destroy Medicare, his life's dream. Will Trump be able to-- or even want to-- stop him?

Ryan has been pushing his privatization plan-- or what he calls "premium support"-- for years. It's been part of his annual budget blueprints, and it has evolved over time. The basic idea is that Ryan would give the elderly a set amount of money to buy health insurance rather than Medicare's fee-for-service system where the government pays doctors and hospitals based on the services they provide.

How much money the elderly would receive to buy insurance, the quality of the plans available, how the government would regulate them and the rate at which the benefits would increase have varied over the years and sometimes have been unclear.

As Medicare is currently configured, American workers and employers contribute equally to the public insurance program via the Medicare payroll tax. When people turn 65, they become eligible for Medicare's guaranteed coverage, pay premiums and receive a robust package of benefits.

Looming as the biggest unknown is whether Medicare-- in its current form as a single-payer, guaranteed-coverage, fee-for-service system-- will remain intact.

Will Medicare be eliminated explicitly, as it has in past Ryan plans? Will it be changed so substantially that the long-term effect will be to weaken it so that phasing out it out is inevitable? Or will Ryan seek to change Medicare in fundamental ways while still preserving its most important protections?

How committed President-elect Trump and Rep. Tom Price (R-GA), his nominee as secretary of Health and Human Services, are to Medicare privatization is another wild card in the mix.

"It is quite clear at this point that Ryan and Price would say they are retaining traditional Medicare as an option, but the question is under what terms. Is it provided under terms that would allow traditional Medicare to continue and flourish? Or is it conversely under terms that would cause it to wither and perish?" said Paul Van de Water, a senior fellow at the Center on Budget and Policy Priorities.

Over the years, Ryan's plans have evolved, in part because of pressure from his own members. Ryan told the New Yorker in 2012 that he recognized his plan needed to be accepted by more than just a few conservatives in the House. He needed to develop a plan that met the vision for the broader Republican conference.

...[T]he underlying principle for Ryan's plans comes from the conservative idea that private businesses are more efficient at managing health care than the government would be. That, some experts argue just isn't true. Medicare, by and large, is a fairly efficient program. Seniors manage to get a lot of health care they are happy with for a decent price.

"Medicare is more efficient than private insurance for two main reasons. One it is able to pay providers less and second it also because of its size, it has lower administrative costs as well," Van de Water said.

Health care experts who have spent years analyzing Ryan's plans note that there are still a lot of questions to be answered. Here's what we do know:

Ryan's 2008 Plan On Medicare: Ending Medicare

In 2008 when he was the ranking member of the House Budget Committee, Ryan proposed that traditional Medicare should be replaced with a voucher program. The idea was that individuals would get a set amount of money from the government to purchase health insurance and eventually Medicare would be phased out.

...Ryan's 2011 Budget: Ryan Works To Phase Out Medicare

In 2011-- after months of listening sessions with his Republican colleagues-- Ryan released his budget, titled Path to Prosperity, which again proposed a major overhaul to Medicare, but had greater support in the wake of Tea Party takeover of the House of Representatives by Republicans who ran on cutting the federal deficit. It left Medicare intact for existing beneficiaires but newly eligible participants would be funneled to an exchange where private insurers competed and individuals could choose private plans. This was Ryan's phaseout plan.

...Experts argued that the plan would put more cost on individuals than they would incur under traditional Medicare and that administrative costs associated with the plans actually eradicated any savings to the government.

"The Congressional Budget Office estimates that under the Ryan plan the cost-increasing effects would swamp the cost-reducing effects, so much so that by 2030 the overall cost of care for the Medicare population would be at least 41 percent higher than it would be under Medicare and the amount that enrollees would have to pay directly would more than double," Henry Aaron – a Brookings Institution fellow who co-wrote his own premium support plan in the 1990s– wrote in a paper on premium support. Ryan claimed in numerous interviews that his proposed changes to Medicare actually were based on the plan that he and Rivlin developed together. “Alice Rivlin and I designed these Medicare and Medicaid reforms,” Paul Ryan said at the time, according to the Washington Post. Rivlin, however, fully rejected Ryan's revised "premium support" plan.

...Ryan's Plan Has Evolved To Leave Some Form Of Traditional Medicare In Place

In more recent years, Ryan's plan has evolved. The idea is still the same. Senior citizens would get a set dollar amount to buy health insurance. Yet, instead of giving voucher recipients only the option to buy private insurance on a health insurance marketplace, the elderly could choose to use their subsidy to buy traditional Medicare.

...[S]ome health care policy experts argue that traditional Medicare could still be jeopardized under Ryan's later privatization plans. Here's the issue. Under Ryan's privatization plan, it's understood that the government will give a set amount of money for individuals to buy insurance, but that dollar amount would be determined by a bidding process of private insurers. Experts are not convinced that quality protections would be strong enough so they worry that the competitive bids could be far cheaper than traditional Medicare in many places, but not be near the quality of the coverage. In that case, individuals who might be interested in going with traditional Medicare to ensure they had more protections may have to pay out of pocket.

"They might have to pay more and they might have to pay a considerable amount more depending on where they are," said Stuart Guterman, a senior scholar at the Commonwealth Fund. "It’s not overtly phasing out Medicare, but it does clearly put pressure on some folks in some areas."

Guterman also worries that even if traditional Medicare were an option, it might be strained if enough younger, healthier beneficiaries opted for private plans, older, sicker individuals stayed with Medicare. It could result in Medicare slowly losing it's power to set competitive prices for services.

“I think it’s a legitimate concern if the mix shifts so that fewer and fewer Medicare beneficiaries are enrolled in traditional Medicare. Then it would be harder for them to set prices effectively," said Guterman.

2016: Ryan Blames Medicare Overhaul On Obamacare

On the campaign trail, Trump boldly declared that Medicare would remain the same for seniors. He argued that the program was not going to be touched. But as soon as Trump won, Ryan appeared on Fox News and argued that something had to be done about Medicare and hinted that it might come as part of the repeal to the Affordable Care Act.

"Because of Obamacare, Medicare is going broke," Ryan said in an interview. "So you have to deal with those issues if you're going to repeal and replace Obamacare."

The reality is that changes to Medicare made by Obamacare actually made the program more solvent, not less. The Medicare trustees wrote in 2010 that "the financial status of the Hospital Insurance trust fund is substantially improved by the lower expenditures and additional tax revenues instituted by the Affordable Care Act. These changes are estimated to postpone the exhaustion of HI trust fund assets from 2017 under the prior law to 2029."