Apparently you don’t have to be all that smart to win a Nobel Prize!

Health Care in a Time of Sabotage

Paul Krugman | July 21, 2017

Is Trumpcare finally dead? Even now, it’s hard to be sure, especially given Republican moderates’ long track record of caving in to extremists at crucial moments. But it does look as if the frontal assault on the Affordable Care Act has failed.

And let’s be clear: The reason this assault failed wasn’t that Donald Trump did a poor selling job, or that Mitch McConnell mishandled the legislative strategy. Obamacare survived because it has worked — because it brought about a dramatic reduction in the number of Americans without health insurance, and voters didn’t and don’t want to lose those gains.

Unfortunately, some of those gains will probably be lost all the same: The number of uninsured Americans is likely to tick up over the next few years. So it’s important to say clearly, in advance, why this is about to happen. It won’t be because the Affordable Care Act is failing; it will be the result of Trump administration sabotage.

One wonders: if the Affordable Care Act was the rousing success that the esteemed Dr Krugman tells us that it is, why isn’t Hillary Clinton President? If the ACA has been so wonderful, why have the Democrats lost 1,041 congressional, gubernatorial and state legislative seats to Republicans campaigning against ‘Obamacare?’¹

Some background here: Even the A.C.A.’s supporters have always acknowledged that it’s a bit of a Rube Goldberg device. The simplest way to ensure that people have access to essential health care is for the government to pay their bills directly, the way Medicare does for older Americans. But in 2010, when the A.C.A. was enacted, Medicare for all was politically out of reach.

It should be noted here that I have already written in support of a single-payer health care plan, one which generated a lot of comments in the RedState version, but Dr Krugman’s statement raises an obvious question: if he admits that the ACA is “a bit of a Rube Goldberg device,” how can he concomitantly state that the ACA failing “won’t be because the Affordable Care Act is failing; it will be the result of Trump administration sabotage?” It’s failing because it couldn’t work, which is what conservatives said all along.

The unfortunate fact is that the Republicans have been completely unable to repeal the ACA: the law remains as it was passed by Congress in 2010. If it was able to be successful the way it was passed, it would be successful now, because President Trump and the Republicans have been unable to change it.

What we got instead was a system with a number of moving parts. It’s not as complex as all that — once you understand the basic concept of the “three-legged stool” of regulations, mandates and subsidies, you’ve got most of it. But it has more failure points than, say, Medicare or Social Security.

Notably, people aren’t automatically signed up for coverage, so it matters a lot whether the officials running the system try to make it work, reaching out to potential beneficiaries to ensure that they know what’s available, while reminding currently healthy Americans that they are still legally required to sign up for coverage.

You can see this dependence on good intentions by looking at how health reform has played out at the state level. States that embraced the law fully, like California and Kentucky, made great progress in reducing the number of the uninsured; states that dragged their feet, like Tennessee, benefited far less. Or consider the problem of counties served by only one insurer; as a recent study noted, this problem is almost entirely limited to states with Republican governors.

If you follow Dr Krugman’s link to the “states which embraced the law,” and click on the Medicaid filter, you’ll see that good, liberal California dropped from 16% uninsured in 2013 (when the ACA took effect) to 9% uninsured in 2015 (the last year documented) also saw Medicaid rise from 23% to 28%; the majority of the drop in the uninsured was a result not of people getting private insurance, but of people getting on Medicaid. The percentages weren’t quite as bad in Kentucky, but the Bluegrass State saw its Medicaid roles jump from 22% to 25% in those two years.²

This isn’t a story about how more people are getting private insurance; this is a story of more people getting on a form of welfare!

But now the federal government itself is run by people who couldn’t repeal Obamacare, but would clearly still like to see it fail — if only to justify the repeated, dishonest claims, especially by the tweeter in chief himself, that it was already failing. Or to put it a bit differently, when Trump threatens to “let Obamacare fail,” what he’s really threatening is to make it fail.

On Wednesday The Times reported on three ways the Trump administration is, in effect, sabotaging the A.C.A. (my term, not The Times’s). First, the administration is weakening enforcement of the requirement that healthy people buy coverage. Second, it’s letting states impose onerous rules like work requirements on people seeking Medicaid. Third, it has backed off on advertising and outreach designed to let people know about options for coverage.

States “impos(ing) onerous rules like work requirements on people seeking Medicaid?” How utterly horrid that we ask people on welfare to look for work to continue to receive welfare! This is a good thing, not something bad.

Despite Dr Krugman’s claims, we noted, in October of 2016, before the election, that ACA premiums were rising by 25%,³ long before President Trump was able to ‘sabotage’ the ACA by doing anything other than campaigning against it.

And here is the worst of Dr Krugman’s idiocy:

And there may be worse to come: Insurance companies, which are required by law to limit out-of-pocket expenses of low-income customers, are already raising premiums sharply because they’re worried about a possible cutoff of the crucial federal “cost-sharing reduction” subsidies that help them meet that requirement.

The insurance companies were already raising premiums, dramatically, before Mr Trump was elected. Insurance companies were pulling out of ACA insurance provider pools before the 2016 elections, leaving, as linked above, about 20% of all consumers served by only one ACA insurance provider. The insurance companies thought that they’d make money on the ACA, with the law forcing the uninsured to buy coverage, that coverage subsidized by the government. Some of that has happened, though much of the reduction in the uninsured is from Medicaid, but the insurance companies are losing money on the law, not making money, and that was happening while President Obama was still in office.

Virtually everything Dr Krugman has said has turned out to be wrong. To some of us, that isn’t a surprise.
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Cross-posted on The First Street Journal.
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¹ – Dr Krugman would probably answer, “Gerrymandering!” but the twelve gubernatorial and twelve Senate seats lost were in statewide elections, where gerrymandered districts aren’t possible.
² – Kentuckians were so happy with former Governor Steve Beshear’s (D-KY) ’embracing’ of the law that, in the 2015 elections, they rejected Democrat Jack Conway, who had a 45% to 40% lead in late polling, giving Republican Matt Bevin, the TEA party favorite who had previously lost the 2014 senatorial nomination to Mitch McConnell, a 53% to 44% over Mr Conway. A year later, the voters in the Bluegrass State flipped the state House of Representatives to Republican control with an overwhelming victory, flipping 17 seats in the 100-member chamber from Democrat to Republican.
³ – “When Obamacare open enrollment begins in 2017, the cost of mid-level plans will rise by an average of 25 percent in the 39 states served by the federal online exchanges. In addition, major providers like Humana, UnitedHealth, and Aetna have scaled back or dropped out of the Obamacare exchanges, leaving roughly 20 percent of consumers with only one insurer to choose from.”