GOP Health Care Sabotage

May 5, 2019

The worst thing that Attorney General William P. Barr did last week arguably had nothing to do with possible contempt of Congress or the Mueller report. It had to do with health care. On Wednesday, amid the circus over alleged special counsel snittiness, the department that Barr oversees asked a federal appeals court to strike down the entire Affordable Care Act, jeopardizing access to health care for tens of millions of Americans. If the Trump administration prevails, everything in the law would be wiped out, protections for people with pre-existing conditions, Medicaid expansion, income-based individual-market subsidies, provisions allowing children to remain on their parents’ insurance until age 26, requirements that insurance cover minimum essential benefits such as prescriptions and preventive care, and so on. The administration’s rationale was laid out in a brief supporting a lawsuit challenging Obamacare by 20 red states. Their logic: When Congress, as part of President Trump’s 2017 tax cuts, set the penalty for not carrying health insurance to zero, that effectively made it no longer a “tax,” and made it unconstitutional. Somehow, that rendered the rest of the law unconstitutional, as well — including lots of provisions having nothing to do with the mandate. This reasoning has been rejected even by conservative legal scholars opposed to the law. But legal merits aside, it’s unclear what political upside Republicans could see in mounting yet another overt attack on Obamacare. The GOP’s November congressional losses were largely motivated by voter rage over the party’s attacks on Obamacare, after all. Trump has, of course, more recently proclaimed the GOP the “party of health care,” and he and other party leaders repeat the obvious fiction that they’re cooking up “something terrific” to replace the ACA. Yet Trump’s party has never come up with a replacement plan, even when it had unified control of government. There are productive things to improve the health care system that don’t involve dismantling the ACA. Obamacare, after all, did a lot to expand coverage and not nearly enough to improve affordability. If Republicans want fruitful areas for improvement, they might contemplate a survey focused on employer-sponsored insurance plans that was released Thursday by the Kaiser Family Foundation and the Los Angeles Times. About half of the U.S. population has employer-based coverage, including 60 percent of nonelderly adults. While most say they are generally satisfied with these health plans, many nonetheless struggle with the financial burden they impose — particularly the high-deductible plans that cover 4 in 10 people with employer-sponsored insurance. Deductibles in employer-sponsored insurance have been rising since long before the ACA. They have nearly quadrupled over the past 12 years and average $1,350 for a single-person plan. But separate survey data show that only half of nonelderly, one-person households report having at least $2,000 in savings available. It’s no wonder, then, that many with “good” health coverage have trouble paying for it. Half of adults with job-based coverage say they or someone in their household has skipped or delayed getting medical care or filling prescription drugs in the past 12 months because of cost. Figuring out how to reduce out-of-pocket costs — including deductibles so high that they’re tantamount to not having insurance — is much more challenging than simply burning down the entire system. After all, requiring employers to spend more on health insurance might hit workers in the form of lower wages. Even so, there are promising paths forward. For instance, the latest version of a plan known as the Medicare for America Act — introduced Wednesday by Democratic Reps. Rosa L. DeLauro, of Connecticut, and Jan Schakowsky, of Illinois — would create an expansive public insurance option to compete with the employer-sponsored system. The public option would cap premiums and out-of-pocket costs and have no deductibles. The bill would allow employer-sponsored plans to continue, as long as they covered a minimum average share of enrollees’ health expenses. Trump administration officials may not like such options. Fine. But if they’re going to persist in trying to blow up the current system — through administrative sabotage, funding cuts and bogus court challenges — the onus remains on them to propose better ways to rebuild it. CATHERINE RAMPELL is a columnist for The Washington Post. crampell@washpost.com