Timothy Jost, Emeritus Professor at the Washington and Lee University School of Law, is one of the nation’s foremost experts on government health care policy. I asked him to respond to some of Congressman Goodlatte’s statements in reply to an interviewer’s question on June 27 on radio station WIQO about the the Congressional Budget Office’s report that more than 20 million Americans stand to lose health insurance if Congress approves Republican legislation to “repeal and replace” the Affordable Care Act:
Congressman Goodlatte is simply repeating here standard Republican health care talking points. It is not clear that he has read either the House or Senate bills or the Congressional Budget Office Reports or Centers for Medicare and Medicaid Services Chief Actuary’s report on the bill. By avoiding actually meeting with his constituents in town hall meetings, and rather limiting himself to interviews with reporters who are incapable of or unwilling to challenge his statements, Goodlatte avoids having to confront the actual damage the Republican proposals would do. Let’s examine each statement:
“Overall, let me just say about the number of people who may not be covered, a large percentage of those people are people who will voluntarily decide that the don’t want to purchase health insurance.”
The CBO report on the House bill that Goodlatte voted for projected that 23 million fewer Americans would have health insurance under the House bill than under the current Affordable Care Act. Goodlatte is correct that the CBO report estimates that 14 million fewer people would have coverage in 2018 under the Republican bill than under current law, and that many of these would drop or not renew coverage because of the repeal of the individual mandate penalty. This number is probably too high. But by 2026, the CBO projected that 23 million would lose coverage. About 14 million of these would be people who lose Medicaid coverage because of the Medicaid cuts and about 8 million who would lose coverage in the individual market because tax credits are cut and because the coverage becomes much skimpier and not worth the trouble of buying for many people.
“And remember, there are 30 million people today, even though they are mandated under what I think is a faulty Supreme Court ruling of a few years ago, 30 million people who chose not to get health insurance even with a law mandate that they must get health insurance or pay a fine. So that’s one part of it.”
It is true that, even though the Affordable Care Act has reduced the level of uninsured to historically low levels in the United States, 25-30 million people remain uncovered. It is hard to see how this is an argument for increasing the number of uninsured by another 23 million, but apparently Congressman Goodlatte seems to think that is the case. So why do people remain uninsured?
First, about 16 percent of those uninsured are undocumented immigrants whom Goodlatte has no intention of helping. Another 12 percent live in states like Virginia that have not expanded Medicaid and thus can’t afford healthcare but are not offered the help the ACA intended them to receive. Many of the remaining uninsured are eligible for Medicaid or for premium tax credit assistance, but do not know that this is the case. Many of these qualify for one of the exceptions to the individual mandate, such as having income below the filing limit. Some pay the penalty. Obviously, what is needed is more aggressive outreach to tell people that coverage is available, and additional help for those who can’t afford coverage, but Goodlatte would rather take coverage away from those who already have it.
“The other part of it is that people who will come off of this are the states that expanded Medicaid. That will be another large percentage of this 22 million that CBO says will not have health insurance. Since Virginia did not expand, we’re not going to experience that aspect of the problem.”
It is true that millions who will lose coverage will be from Medicaid expansion states, and that since Virginia never expanded Medicaid, these losses will not directly affect Virginia. But the logic here is bizarre. It is like saying that refugees who are starving to death in a refugee camp that has received no relief supplies should count themselves lucky that they will not be affected by the cut-off of relief supplies to another refugee camp that was receiving help. Of course, if the ACA remains in place Virginia could expand Medicaid in the future. That course of action will be cut off by the House or Senate bills. Moreover, both the bills cut Medicaid dramatically in the future. The Senate bill would reduce projected Medicaid spending by 26 percent in 2026 and 35 percent in 2036. It is clear that cutbacks of this magnitude will not just affect the expansion population, but also traditional Medicaid recipients— the elderly, disabled, children and their families, and pregnant women— who will lose services, access to providers, and even eligibility.
“Finally CBO has gotten this wrong year after year after year with Obamacare. So I’m not sure I trust their analysis with how this new law would work.”
It is true that the CBO’s projections of coverage under the ACA did not come out exactly right. Predicting what will happen with expenditures and coverage far into the future is difficult. It is particularly difficult to predict developments like a Supreme Court decision that would cut the legs out from under ACA Medicaid coverage and that surprised virtually all Supreme Court observers. But in fact the CBO has done better than anyone else in predicting developments under the ACA. And for better or worse, the CBO is Congress’ own nonpartisan scorekeeper, and Goodlatte cannot simply accept their projections when he agrees with them and reject them when they don’t support his case.
“What I do know is this will save the taxpayers a lot of money, it will give consumers more choice, it will lower health insurance premiums by up to 30 percent, which will make a big difference, which will encourage people to get health insurance.”
Specifically, the legislation will save very wealthy taxpayers, like Goodlatte, a lot of money. The House bill would have cut taxes by about a trillion dollars over ten years, with a quarter of that going to taxpayers making more than a quarter of a million dollars a year, and most of the rest to big corporations. The CBO projected that enactment of the House bill would initially raise premiums by 20 percent over current trend, but that by 2026 premiums would fall to 30 percent below current levels. The specific reason for this, however, was that coverage would become much skimpier— with higher deductibles, fewer benefits, and in some cases exclusion of preexisting conditions. Overall, the premiums for buying a plan equivalent to today’s marketplace coverage under the Senate bill would increase 74 percent by 2020.
“And they’ll have choices they can afford, whereas right now a federal bureaucracy tells every insurance company what needs to be in every plan. And in order to make the plans affordable they provide people with extraordinarily high deductibles– $7,500, $8,000, $10,000 deductibles. For a lot of people that’s almost meaningless except when it comes to a catastrophic illness. It’s not insurance in their minds.”
This claim is simply bizarre. What the House and Senate bills do is to allow insurers pathways to offering fewer benefits with higher cost sharing. In fact, under the ACA many insureds have high deductible policies. But people with incomes below 250 percent of the poverty level get cost-sharing reductions that dramatically reduce their actual cost sharing while many insurers offer basic services, like doctor visits, before the deductible kicks in. All analyses agree that deductibles and other forms of cost-sharing would go up dramatically under the Republican bills. In particular, older people would have to pay much higher premiums to get coverage like they get today. Insurers would not be able to offer services before the deductible.
“In addition we think we’ll have lower-deductible, affordable policies.”
This is simply not true. No responsible analysis projects this. It is possible that insurers will offer policies that exclude preexisting conditions and do not cover mental health services or prescription drugs and that have low-annual limits for lower premiums. But if you find this kind of coverage, make sure you never get sick.
“But for those who want high deductibles, we will have a vastly improved medical savings accounts program that will allow people to double the amount they put into their plans tax-free.”
Health savings accounts are a great tax shelter for wealthy people, who have extra income to invest in a tax-free account. They do little or nothing to help lower-income Americans who have benefited from the ACA. But the Republican legislation is all about helping the wealthy, and making life harder for the poor.
Congressman Goodlatte has the week off this week. He should spend it meeting with his constituents and learning how the ACA has affected their lives. Unfortunately, he is too cowardly to do so. He would rather spend his time on foreign junkets and meeting with wealthy donors. Perhaps if he talked to real people, he would learn that the talking points he is repeating do not reflect reality.
Goodlatte Watch 