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Donald Trump listens to a speaker in the East Room of the White House on Friday. Photograph: Mandel Ngan/AFP/Getty Images
Donald Trump is used to running private companies with him as President, and enjoying the Presidential power private companies provide. Now he finds being President of the United States isn’t the same as being President of Trump Organization.
Republicans, who voted more than 60 times to repeal or alter Obamacare over the past few years only to be vetoed by Obama, had got their big chance and blown it. The party’s deep ideological and factional divisions, temporarily papered over amid the euphoria of last November’s surprise win, were back with a vengeance as it struggled to go from opposition to governance.
In Trump’s rambunctious election campaign, the 70-year-old novice promised to repeal and replace the ACA “immediately”. It was a bad choice for an opening offensive. Healthcare reform is to American presidents what the Russian winter was to Napoleon.
Trump has said tax reform is next, and years of Republican planning might allow for that legislation to pass more easily. But his ability to work with Congress is in grave question. His unique selling point, as a dealmaker, has taken a huge hit.
Gwenda Blair, a Trump biographer, said of Trump’s supporters: “They voted for a guy who could fix it, the CEO, on The Apprentice for 10 years, who could make a deal with anybody.”
But the tactics that served Trump so well in business – playing the alpha male, holding one-on-one meetings – did not translate to politics, she said.
“Now he’s up against 535 other people [in the House and Senate], other people who have their own independent power base and are not really interested in rolling over. The model of taking one person in a room and beating up on them doesn’t work with 535.”
But as the health care bill negotiations gathered steam, it was clearly not going to be plain sailing. Last month, Trump admitted: “Now, I have to tell you, it’s an unbelievably complex subject. Nobody knew healthcare could be so complicated.” The bill was, in the eyes of many, rushed and deeply flawed, falling well short of Trump’s campaign pledge to provide insurance for everyone.
Grassroots protests erupted across the country, citizen activists hitting the phones and constituents berating congressmen at town hall events. Groups representing hospitals and medical professionals derided the legislation. The non-partisan Congressional Budget Office estimated that the AHCA would lead to 24 million fewer Americans having health insurance over the next 10 years. The bill achieved the rare feat of uniting the far left and far right in opposition.
Friday’s failure was a fillip for the anti-Trump “resistance” but it was hardly grounds for complacency. The president looks set to press ahead with his agenda on everything from rolling back Obama-era protections on the environment to building a wall on the Mexican border to firing off tweets that alienate allies and embolden enemies.
He may also ensure that his prediction of Obamacare’s explosion becomes a self-fulfilling prophecy. “Move fast and break things” will continue, even it if means breaking his own party.
Donald Trump: pointing the way toward … more of the same for the wealthy, actually. Photograph: Timothy A Clary/AFP/Getty Images
Effects on Health Insurance Coverage
To estimate the budgetary effects, Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT) projected how the legislation would change the number of people who obtain federally subsidized health insurance through Medicaid, the nongroup market, and the employment-based market, as well as many other factors.
CBO and JCT estimate that, in 2018, 14 million more people would be uninsured under the legislation than under current law. The increase in the number of uninsured people relative to the number under current law would rise to 21 million in 2020 and then to 24 million in 2026.
The reductions in insurance coverage between 2018 and 2026 would stem in large part from changes in Medicaid enrollment—because some states would discontinue their expansion of eligibility, some states that would have expanded eligibility in the future would choose not to do so, and per-enrollee spending in the program would be capped.
In 2026, an estimated 52 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.
Most of that increase would stem from repealing the penalties associated with the individual mandate. Some of those people would choose not to have insurance because they chose to be covered by insurance under current law only to avoid paying the penalties, and some people would forgo insurance in response to higher premiums.
Effects on Premiums
The legislation would tend to increase average premiums in the nongroup market prior to 2020 and lower average premiums thereafter, relative to projections under current law. In 2018 and 2019, according to CBO and JCT’s estimates, average premiums for single policyholders in the nongroup market would be 15 percent to 20 percent higher than under current law, mainly because the individual mandate penalties would be eliminated, inducing fewer comparatively healthy people to sign up.
Starting in 2020, the increase in average premiums from repealing the individual mandate penalties would be more than offset by the combination of several factors that would decrease those premiums: grants to states from the Patient and State Stability Fund (which CBO and JCT expect to largely be used by states to limit the costs to insurers of enrollees with very high claims); the elimination of the requirement for insurers to offer plans covering certain percentages of the cost of covered benefits; and a younger mix of enrollees.
By 2026, average premiums for single policyholders in the nongroup market under the legislation would be roughly 10 percent lower than under current law, CBO and JCT estimate.
Although average premiums would increase prior to 2020 and decrease starting in 2020, CBO and JCT estimate that changes in premiums relative to those under current law would differ significantly for people of different ages because of a change in age-rating rules.
Under the legislation, insurers would be allowed to generally charge five times more for older enrollees than younger ones rather than three times more as under current law, substantially reducing premiums for young adults and substantially raising premiums for older people.
Helping the richest
For many lower-income people, the new tax credits under the legislation would tend to be smaller than the premium tax credits under current law. Conversely, the tax credits under the legislation would tend to be larger than current-law premium tax credits for many people with higher income.
How stupid is the current BC government? Quite stupid. B.C.’s per-capita spending on drugs is currently 27 per cent less than the average level in the rest of the country, and this level likely to rise with changes proposed by government to allow far more input by drug companies when the government is considering drug approval.
An internal health ministry document says there will now be four separate opportunities for drug marketers to make their case while new products are being considered for coverage by B.C.’s PharmaCare plan.
At the same time, the government’s long-standing drug review body with an arms-length distance from the industry is being abolished. The Therapeutics Initiative’s cautious approach to drug approvals has been credited with saving lives and helping B.C. maintain the lowest per capita spending on prescription drugs in the country.
Michael McBane of the Canada Health Coalition said no other provincial drug plan allows as much industry involvement as B.C. is proposing.