Tag Archives: healthcare

What would a Republican healthcare plan look like?

November 10, 2025 – 11:04 am

The government can cut healthcare spending if it tempts people into gambling with their lives.

The longest government shutdown in American history came down to one issue: healthcare. Republicans have been persistent about dismantling the ObamaCare model, claiming that they have a different approach that will yield better care for less cost. And so the subsidies that kept policies on the ObamaCare marketplace affordable have been allowed to lapse for 2026 policies. Democrats tried to reverse that as a condition of reopening the government, but appear to have failed.

Of course, Trump has been promising to spell out a “beautiful” healthcare plan since 2015, and we’ve still seen nothing. Critics say Republicans don’t really have a plan, which is true in the sense that they don’t have a written piece of legislation that can be compared to the Affordable Care Act, apples to apples. (They also have nothing that could take effect in time to replace the 2026 ObamaCare policies they have now made unaffordable for millions of Americans.) Rep. Marjorie Taylor Greene makes an even stronger claim, that even within the Republican House conference, Mike Johnson has not yet presented “a single policy idea”. Speaker Johnson counters that Republicans have “pages and pages and pages of ideas of how to reform healthcare”, and has pointed to a report the Republican Study Committee wrote in 2019.

It’s natural and probably appropriate to be cynical about that claim, but for a few minutes let’s take Speaker Johnson seriously. What’s in that report? It’s 58 pages, most of which are spent criticizing ObamaCare. But it does get around to presenting some ideas on pages 32-50: things like health savings accounts, allowing a wider range of choices in insurance, changes to the way employer-paid premiums are taxed, and so on — enough individual notions to get you confused about the overall picture. But basically it comes down to this: They want you to gamble with your life and health.

In order to understand their proposals, let’s lay out the context: starting with the pre-ObamaCare situation, then what ObamaCare did, and then the ways Republicans have broken ObamaCare since.

Before ObamaCare. When the Affordable Care Act was passed in 2010, about 16% of Americans — 48 million in all — did not have health insurance, and the number was growing every year. Tens of millions of others (the exact number depends on your definitions) had some form of “junk insurance” — a policy that worked just fine for relatively minor things like a broken arm, but would leave you in a lurch if you developed some really expensive condition.

People were uninsured for a variety of reasons: Some couldn’t get insurance because they had pre-existing conditions like cancer or heart disease that made them bad risks. Others were young and healthy and saw no reason to pay significant amounts of money for care they believed they would never use. (I did this myself at age 21 in the summer between my undergraduate and graduate-school coverage. Looking back, I feel foolish about that gamble, but I got away with it.) For others, health insurance had to compete with rent and food for their limited resources. Or perhaps their health was not so bad as to make them uninsurable, but bad enough that the rates they were offered were astronomical.

Junk insurance came in a variety of forms. Maybe, if you had survived some expensive illness like cancer, it would specifically exempt any condition related to a return of that illness. Maybe it would have an annual or a lifetime cap on what it would pay out. (If you had a debilitating disease like MS, or a child born with significant birth defects — as my college roommate did — you might go over that lifetime cap in just a few years. Then you’d be uninsurable.) Maybe it would have to be renewed every year or two, giving the insurance company a chance to drop you if it wasn’t making money on your policy.

In short, somewhere between 1/4 and 1/3 of Americans lived with the worry that if they needed significant medical care, they wouldn’t be able to pay for it.

The roots of ObamaCare. This healthcare anxiety is a uniquely American problem, because other rich countries don’t regard medical expense as a personal responsibility, and instead pay for it through some national system. Statistics argue in favor of that approach: Among wealthy nations, the US stands out both for its per capita spending on health care, and for its low life expectancy. So we pay more, but get worse results.

But national healthcare is “socialism”, which is anathema to American conservatives. So in an attempt to stop the US from opting for a European-style national health system, the conservative Heritage Foundation created a different model in a 1989 report. The basic idea was that you achieve 100% coverage through a private-insurance system by

  • mandating that individuals have insurance
  • forcing insurance companies to cover everybody who wants their coverage
  • subsidizing insurance for those who can’t afford it

That model was the basis for the RomneyCare plan that Massachusetts adopted in 2006 under Republican Governor Mitt Romney. RomneyCare in turn begat ObamaCare in 2010.

So this is an important thing to understand about the politics of healthcare: Republicans have had a hard time coming up with a healthcare plan because Obama stole their plan. He left them with a difficult choice: They could have declared victory, but that would have meant joining forces with the Black guy in the White House, which was unimaginable.

I have occasionally wondered how Mitt Romney would have fared in 2012 if he could have run on his record as the Father of ObamaCare and general solver-of-impossible-problems. But this was not to be.

What Obama did. In addition to the Heritage Foundation’s mandate-and-subsidize idea, Obama and Romney recognized the patchwork way that most Americans were already covered: If you were old, you had Medicare; if you were poor, you had Medicaid; children got covered under CHIP; veterans had the VA; people with good jobs got coverage through their employers. American healthcare was like a big bed with a lot of small blankets that covered most people, but not everybody.

So a second fundamental idea of ObamaCare was to make the blankets bigger: Insist that companies employing more than 50 people full time had to offer health insurance, expand Medicaid so that it covered the working poor as well as the destitute, and so on.

Even the bigger blankets wouldn’t stretch to cover everybody, so the ObamaCare exchanges were created: marketplaces where individuals could buy their own policies, without regard to their previous health record, and with a sliding scale of subsidies depending on income.

The mandate-and-subsidize system only works if the term “insurance” actually means something, so ObamaCare also defined what private insurance had to cover. In particular, this made junk insurance illegal. Annual and lifetime caps were gone, as were provisions not to cover certain common problems. Many people who had junk insurance didn’t realize the risks they were taking, and resented the fact that their cheap policies were now illegal. This is how Obama’s claim that “If you like your plan you can keep” got picked out as the Lie of the Year for 2013. (Personally, I liked my employer-provided insurance, and I kept it.)

And it all sort of worked. As you can see in the graph above, the number of uninsured began to drop after 2010, dropped more when the exchanges came online in 2014, and didn’t start rising again until Republicans began breaking the system during the first Trump administration. And these numbers don’t give the ACA credit for the number of people whose junk insurance was replaced by real insurance.

John McCain turns thumbs-down on repealing the ACA with no replacement.

How Republicans have sabotaged ObamaCare. Republicans have tried to repeal the Affordable Care Act again and again ever since it was passed — at least 63 times in all. Their effort always foundered on the same point: Repealing the ACA would instantly create about 20 million uninsured Americans, and the Republicans had no plan for dealing with them. The closest they came was in 2017, with the slogan “Repeal and Replace”, where the “replace” half was always left vague. That vote came down to John McCain’s famous thumbs-down moment.

But failing to repeal didn’t mean failing to sabotage. The most obvious bit of sabotage was the ultimately successful attempt to end the individual insurance mandate, which assessed a penalty on people who went uninsured. At first they tried to undo it through the courts, and nearly succeeded. The Supreme Court overturned decades worth of interpretation of the Constitution’s Commerce Clause to find that it didn’t allow the penalty. But John Roberts saved the individual mandate by reinterpreting its penalty as a tax.

But Roberts also sabotaged the system by not allowing the federal government to withdraw all Medicaid funding from states that refused to expand Medicaid. This created a two-tier system where some states expanded Medicaid and others didn’t. Gradually, even red states like Oklahoma and Missouri expanded their programs, but 10 states are still holding out.

Republicans finished killing off the individual mandate in the Trump tax cut of 2017, which didn’t eliminate the penalty, but set it to zero. This created a hole in the system: If you’re healthy right now, you can save money by going uninsured, remaining confident that you can get insurance after you develop some health problem.

The RSC’s 2019 report castigates ObamaCare for this hole in the system, which the Republicans created themselves.

Unfortunately, because the ACA created a perverse incentive for people to forgo insurance until they developed an illness, costs across the board rose dramatically, which required higher premiums on the existing plans in the individual market exchanges. Not surprisingly, the premium spikes further repelled healthy individuals.

How Republicans want to “fix” ObamaCare. If you don’t think ObamaCare is working, the obvious way to fix it continues to be a universal single-payer healthcare system, like Bernie Sanders’ Medicare for All. Countries with such systems continue to spend less on healthcare than Americans do, while getting better results in terms of life expectancy.

But Medicare for All is still socialism, which is still anathema. So what can be done?

The report is full of wonderful-sounding words like “choice” and “freedom”, but the essence of it comes down to this: The healthcare system can save enormous amounts of money if it exposes people to more risk.

I’ll give a personal example here: In 2023 I had a scary incident where I lost vision in my right eye for about five minutes. It was like looking at a gray screen. Afterwards, I returned to normal, as if nothing had happened. I’ve had no recurrences in the two years since.

All indications point to this incident being just one of those annoying brain things without long-term significance, like migraine headaches. But it could have been a stroke or a blood clot or a tumor. Medicare spent an huge amount of money checking all that stuff out. I didn’t keep track, but I’m sure it’s well into the tens of thousands.

And it all could have been saved if someone had said, “It’s probably nothing. Let’s ignore it and see if it happens again.”

Now, if some government or insurance bureaucrat says that, it’s horrible. They’re telling me to gamble with my life. But (from the Republican point of view) if I say it, that’s great. So that’s the heart of the Republican program: incentivize people to gamble with their lives.

They do this in a lot of different ways. For one, junk insurance is back.

[I]n order to provide Americans with health insurance options that fit their individualized needs and do not add unnecessary expenses, the RSC plan would undo the ACA’s regulations on essential health benefits, annual and lifetime limits, preventive care cost-sharing, dependent coverage, and actuarial value. … The cumulative effect of these changes would result in Americans being provided with more insurance choices that are personalized to their needs and available at affordable rates.

(“Actuarial value” is essentially a limit on the insurance company’s profit margin.) So if you have a strained budget, a cheaper plan that risks your future if you wind up with some expensive condition is “personalized” for you. It “fits your individualized needs”.

Several provisions are designed to promote individual plans that can be “personalized” in this way. The biggest is to change the tax laws that allow employers to deduct what they spend on employees’ health insurance. With ObamaCare’s employer mandate also gone, this will have the effect of ending a lot of employer-supplied health insurance, pushing all those people into the individual market.

The other big “personalization” tactic is to emphasize Health Savings Accounts. Lots of people have those now for medical incidentals like glasses. But under the Republican proposal, HSAs are cut loose.

Under current law, health savings accounts plans cannot be used in conjunction with plans that are not a “qualified high-deductible health plan.” This unnecessarily hamstrings the ability for millions of Americans to access this important savings tool. Accordingly, the RSC would eliminate this requirement to allow health savings accounts to be utilized even if a person does not have a health insurance plan.

So you can go without insurance and pay your own health expenses out of an HSA. This is the ultimate individualization: Imagine me with an HSA instead of Medicare. My vision blanks out for five minutes, and I’m left with a choice: Do I want to drain my HSA checking out things that probably are OK? Or do I want to just risk it?

The limits of freedom. The unexamined issue in the Republican plan is class. Yes, you have “choices”, but only if you can afford to pay for them. The poorer I am, the more likely I am to risk a junk policy to save money, and the more likely I am to forego testing or treatment if I think it probably works out for me. Those are “choices”, in the same way that poor people “choose” to save money on rent by living in their cars.

Of course, when you’re talking about 350 million people, “probably” leads to many, many cases where the improbable happens. So these personalized decisions will lead to large numbers of medical bankruptcies, and some non-trivial number of unnecessary deaths.

The other thing “freedom” doesn’t take into account is the burden of making good decisions, especially decisions about big issues that involve many details that only experts in the field really understand. As we saw in the real-estate crash of 2008, “freedom” in the mortgage market led to people signing documents they didn’t really understand and losing their homes. More recently, “freedom” from vaccine mandates is allowing diseases like measles and polio to come back.

And if we are all making these decisions as individuals, the success of insurance or healthcare-providing companies depends on their ability to influence those decisions. Think about all the ads you see this time of year boosting “Medicare Advantage” programs (which provide enormous advantages to the companies offering them). That kind of marketing could be round-the-clock for every kind of medical decision. Just as the system forced us to make more decisions, all the corporate powers of persuasion would be focused on manipulating us into choosing badly.

All that marketing would cost an enormous amount of money, which ultimately would have to be reflected in the prices we pay. Would it eat up all the “savings” that result from taking bigger risks with your life? Maybe.

By weeklysift | Posted in Articles | Also tagged | Comments (7)

The Big Beautiful Bill

May 19, 2025 – 9:43 am

Since the Republicans took it over in January, one of our three branches of government has been AWOL: Congress. The Executive branch has been all too active, as President Trump has sought to exercise powers the Constitution does not grant him. That has kept the judicial branch busy as well, processing lawsuits that try to block Trump’s illegal actions.

But where has Congress been? Not only has it passed almost no laws, but it has watched mutely as the Trump administration refuses to spend money it appropriated and closes down agencies it established. The Senate shrugged as Trump nominated one absurdly unfit and unqualified character after another to the most important positions in our government. And as one scandal after another unfolded, Congress has not even held any noteworthy investigative hearings.

However, there is one congressional power that neither the President nor the Supreme Court has yet figured out how to usurp in any major way: authorizing the government to collect taxes and spend money.

So we saw Congress act back in March, when the government was about to run out of money. It did just about the minimum possible: passed a continuing resolution that kept fiscal 2025 spending at more-or-less the same level as fiscal 2024. But the money runs out again when FY2026 starts on October 1.

From the beginning, there’s been pressure on Congress’ Republican leadership to put its mark on the new budget. After all, if the government keeps spending the same amounts of money on the same things, what was the point of giving the GOP control? The Party needs a budget it can take back to its voters and say, “See? This is what you sent us to Washington to do.”

Or, to put it another way: Republicans own the FY 2026 budget. They can’t blame Biden or Nancy Pelosi or any of their usual scapegoats. So what are they going to do?

If you’ve ever managed anything — a household, a church, a business, or whatever — you know that budgets are where the rubber meets the road. You can say lofty things about your values, your principles, or who you care about, but it’s all just words until you have to put numbers on paper. When real dollars start coming in and going out, your rhetoric doesn’t matter any more.

That’s a particular problem for MAGA Republicans this year, because much of what they’ve been telling their voters isn’t true. In particular, they’ve been claiming for years that government spending is full of waste and fraud that serves no legitimate public purpose. So spending can be drastically cut without hurting anybody other than the bureaucrats and the fraudsters. They can spend even more on Trump priorities like border security and missile defense, and still find enough waste and fraud to give big tax cuts to the Dear Leader’s wealthy friends — all without increasing the national debt that they claim is destroying the nation.

But then there are those pesky numbers, and disciplines like arithmetic that they still haven’t managed to write out of the national curriculum. So as of yesterday, when the budget bill squeaked through the House Budget Committee on its second try, it can be summed up in three points:

In theory, this combination — transferring wealth from the working poor to the very rich, while worsening the debt problem Republicans claim is an existential threat to the Republic — should repel the White working-class voters who provided Trump’s margin of victory. But we’ll see. Whatever comes out of this process, Trump will claim that it’s wonderful. Perhaps his MAGA base will be loyal enough and gullible enough to believe him, as they so often do.

What Democrats need to do during this process is keep the discussion focused on things that are real, and cut through Republican attempts to cloud the real issues.

Work requirements. The biggest attempt to cloud the reality of the Medicaid and food stamp cuts is the imposition of work requirements on recipients. This sounds great to the typical MAGA voter, who has been fed story after story of able-bodied young men taking advantage of the system. These moochers, Speaker Mike Johnson says, “need to be out working instead of playing videogames all day.”

Johnson hopes you don’t know that numerous states have imposed work requirements, and it has never worked the way he wants you to believe it will.

When Arkansas applied this policy in 2018, it failed disastrously. Even though nearly all enrollees should have met the work requirement or qualified for an exemption, a large share tripped over the red tape and lost their health care coverage anyway. About 1 in 4 people in Arkansas subject to the requirements—about 18,000 people—lost coverage in just the first seven months of the new policy, before a federal judge determined that the policy violated the purpose of the Medicaid program and put a stop to it.

New Hampshire followed Arkansas’ lead in 2019, and similarly found that about 2 out of 3 enrollees subject to the new policy would have lost their health care coverage in the first two months—so the state suspended the program. Shortly after, it was halted permanently by a federal court.

And in Georgia, the only state allowed to continue a work requirement policy, which applied to a narrow eligibility expansion, the administrative costs to run the program were astronomical—nearly $60 million in the first year to cover just 4,200 people.

Think it through: If you’re going to require recipients to work (or engage in some other worthwhile behavior like school), they’re going to have to provide proof that they’re working, and do it on a regular basis. And you’ll have to hire more bureaucrats to check up on that paperwork.

Now picture the life of typical Medicaid or SNAP recipients, who are not playing video games all day. They’re working 30 hours or more a week at something close to minimum wage, dealing with inefficient public transportation or unreliable car pools because they don’t have a car, and probably juggling child care at the same time. Many of them are not well educated, so they have trouble navigating complex systems. Completing a new set of forms (with supporting documentation) every 90 days or so has a way of slipping through the cracks.

Now think about health insurance. If you’re healthy, nothing happens when you lose health insurance, at least not right away. Your kids will complain if you don’t get dinner on the table, and your boss may fire you if you’re late for work, but if your Medicaid paperwork slides a day or two, that doesn’t seem like an emergency. How are you going to allocate your time?

So yes, the government can save money by imposing work requirements. But those savings come from denying care to people who are actually eligible. (The people who are working the most hours are the ones who will have the hardest time keeping their paperwork up to date.) And much of the savings is eaten up by the increased bureaucracy.

Similar “savings”. The Contrarian reports:

The bill includes a range of other cruel Medicaid policies that should also come out. In yet another play to harass people off of their Medicaid coverage, it would roll back a rule finalized by the Biden administration to modernize and simplify how people enroll and stay enrolled in coverage. Repealing this rule will save the government $162 billion over the next 10 years— largely because rolling back the rule reinstates a lot of unnecessary red tape, which reduces the total number of people enrolled.

ObamaCare. For years Republicans tried to repeal ObamaCare, but now they’re taking refuge in it. Specifically, they argue that people who get kicked out of Medicaid can still get subsidized policies on the ObamaCare marketplaces.

Subsidized, but not free. And that brings up a public-policy aspect of healthcare: We don’t want people to gamble with their health insurance.

I know how this works because decades ago I did it myself: In the two or three months between the end of my final school year and the beginning of my first job-with-benefits, I went without health coverage. It would have cost me hundreds of dollars a month to fill the gap, which seemed like a lot of money to me at the time. I was healthy, so why not risk it?

I got away with it. Lots of people do. But the ones who don’t end up costing our healthcare system a lot of money, because emergency rooms are the least efficient way to take care of people.

Again, if you’re healthy, nothing immediately goes wrong when your health insurance lapses. The kids will suffer if you stop buying groceries, and they’ll complain if they have to keep wearing clothes they’ve outgrown. The landlord may throw you out if you stop paying rent. But if you don’t have health insurance for a month or two, maybe you get away with it. Doing without can look like the easiest way to fill the hole in your budget. And then months stretch into years, until something happens.

We don’t want to tempt people to make that trade-off.

Values. Finally, think about what we’re giving away here: health care and food. We’re not giving poor people sports cars and Super Bowl tickets. If someone “takes advantage” of you to get the medicine and treatment they need, or food for themselves or their families, are you really that upset? How many needy people are you willing to cut off to make sure that some handful of young men aren’t playing video games all day?

If your answer to that question isn’t tiny, you might want to take another look at your moral values.

By weeklysift | Posted in Articles | Also tagged | Comments (6)