![\"https:\/\/commons.wikimedia.org\/wiki\/File%3ADoctor_examines_patient_(1).jpg;](\"https:\/\/wp-media.patheos.com\/blogs\/sites\/533\/2016\/08\/800px-Doctor_examines_patient_1.jpg\")
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Stupid, stupid, stupid, stupid, stupid.<\/p>\n
That\u2019s my overall reaction to the GOP\u2019s new healthcare bill. \u00a0You can read the text here<\/a>, and the GOP\u2019s spin on it here<\/a>. \u00a0Lots of sources for summaries of the bill; you can start with Politico<\/a>. \u00a0So far I\u2019ve read the text itself (which admittedly means missing a lot because so many of the changes are done by means of amending other laws\u00a0in that crazy way that legislation works) and a bit of commentary and wanted to write up a few thoughts before starting my workday. \u00a0(Update: \u00a0OK, I ended up finishing typing this at lunch. \u00a0Also, here\u2019s a more detailed summary<\/a> of the changes in this bill.)<\/p>\n So\u00a0let\u2019s take this in three parts.<\/p>\n The good:<\/strong><\/p>\n Planned Parenthood is (temporarily) defunded<\/strong>. \u00a0Now, to be sure, I don\u2019t see the point of a one-year defunding. \u00a0I guess it\u2019s symbolic. \u00a0And the law doesn\u2019t, as a general principle, establish that no organization which performs abortions is eligible for federal funding, but it specifically defunds Planned Parenthood, by that device of describing the affected entities so specifically that only they are covered \u2014 which admittedly isn\u2019t hard to do as they\u2019re the only nationwide \u201cchain\u201d of clinics, so the bill says it applies to any entity:<\/p>\n \u00a0for which the total amount of Federal and State expenditures under the Medicaid program under title XIX of the Social Security Act in fiscal year 2014 made directly to the entity and to any affiliates, subsidiaries, successors, or clinics of the entity, or made to the entity and to any affiliates, subsidiaries, successors, or clinics of the entity as part of a nationwide health care provider network, exceeded $350,000,000. \u00a0 (page 4 as numbered in the linked text)<\/p><\/blockquote>\n Abortion coverage is wholly removed<\/strong> from \u201cexchange\u201d plans. \u00a0(And, so far as I can tell, the \u201cexchange\u201d mechanism remains \u2014 but I need to check on this later.)<\/p>\n The age differentials have been widened<\/strong> from 3:1 to 5:1 so that young people won\u2019t be subsidizing the near-retirees to the same degree. \u00a0Yes, supporters of those restrictions painted it as \u201cunfair\u201d that oldsters had more expensive premiums, but the reality is that they also, on average, have higher wages, and, in any case, requiring the young \u2018uns to pay more than is actuarially fair simply causes them to reject health insurance.<\/p>\n The employer mandate eliminated<\/strong>. \u00a0So far as I understand, this had not had much, if any, beneficial effect in terms of increasing coverage, but had only resulted in hourly workers at low-wage jobs being reduced to 29 hours per week.<\/p>\n The caps on HSAs<\/strong> have been increased; these caps had primarily impacted people with disabilities or chronic high healthcare costs, not the wealthy that they were intended to hurt.<\/p>\n <\/p><\/blockquote>\n The bad<\/strong>:<\/p>\n The Medicaid expansion is eliminated<\/strong>: \u00a0childless nonpregnant adults no longer covered no matter how poor they are \u2014 which would be fine if there were other mechanisms to provide for their healthcare, but it\u2019s basically status quo ante<\/em>. \u00a0And, yes, studies have shown that adding people to Medicaid was not actually life-saving (controlled studies from certain pre-O\u2019care pilots in which childless adults were randomly chosen to receive government benefits, and the winners and losers of this lottery were evaluated for their health outcomes) but it did provide for their overall well-being.<\/p>\n (Incidentally, they also replace the existing cost-sharing mechanisms with per-capita allottments; is that \u201cgood\u201d or \u201cbad\u201d? \u00a0I haven\u2019t yet formed an opinion.)<\/p>\n The bill replaces exchange subsidies with flat credits<\/strong>, which I would agree with\u00a0in principle, but highly dependent on the amount of the credits, and, so far as I can tell, they are quite inadequate.<\/p>\n Here\u2019s a simple analysis based on information from ehealthinsurance.com<\/a>, using my own zip code (suburban Chicago), and the cheapest possible cost plan, with a $7,100 deductible. \u00a0You can try this with your own area \u2014 perhaps the regional variations are substantial enough that these credits buy more elsewhere.<\/p>\n In the first place, the age-based scale is quite insufficient to make up for the higher costs at older ages, and this\u2019ll only increase when the 3:1 differential is removed. \u00a0And these are credits per individual, so, naturally, a couple will have double the credits, but also double the shortfall between credits and actual cost. \u00a0In addition, so far as I can tell, there is no mechanism in the bill for increasing these credits with inflation.<\/p>\n And these credits might be adequate for someone who is self-employed but with a middle-level income. \u00a0But for the low-income folk, for whom, prior to Medicaid or the subsidies, health insurance was a luxury good? \u00a0In what world are these credits sufficient? \u00a0I suppose, in principle, they could (presuming out-of-pocket limits are removed) buy a plan with, instead of a $7,100 deductible, something twice that, but when you\u2019re talking about such a high deductible level, it\u2019s hard to make the case that the remaining value is still worth the logistical trouble of securing health insurance. \u00a0And if you are planning to give very low income folk catastrophic coverage, then this should be accompanied by a much greater effort at providing access to sliding-scale clinics, which I haven\u2019t seen here or in any other discussion, except for vague statements about grants to states.<\/p>\n![\"HC](\"https:\/\/wp-media.patheos.com\/blogs\/sites\/533\/2017\/03\/HC-credits-1.png\")
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