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Friday, December 14 , 2018, 4:51 am | Fair 52º


Susan Estrich: Under Republican Health-Care ‘Changes,’ You’d Better Be Well

If President Donald Trump and his party have their way, you’d better be well. Or have a lifetime employment contract with a company large enough to negotiate reasonable group insurance. Or have never been sick in your life.

In the bad old days, I tried to buy health insurance for the woman who helped me raise my children, maybe the most important job in the world to me.

I explained that nobody is rich enough (Trump’s Cabinet excluded) to afford to pay for health care if they get sick, but I was, at least, rich enough to buy insurance for her.

The problem, as it turned out, was finding someone to sell it to me. You see, she had a history of gastritis, resulting in a regular prescription for Nexium. I kid you not; that was the stated reason.

No matter how much I was willing to pay, they didn’t consider her worth accepting into the network. They figured she would be increasingly likely to actually use the insurance.

Thank God, and I don’t say it lightly, for Kaiser Permanente, which was willing to take my money and probably made money off her coverage for at least a decade, until cancer struck.

And when it did, she was in surgery faster than my friends who have had to get referrals and approvals; she received phenomenal care from dedicated doctors who scrimped on nothing. She is convinced that Kaiser saved her life. I don’t disagree.

Which brings me to Trump.

It was easy for Republicans to rail against the Affordable Care Act when President Barack Obama held the veto pen.

For years now, it’s been a game — an example of swamp politics at its worst. Republicans repeatedly came close to shutting down the government in what everyone recognized was a purely symbolic effort.

It is not symbolic anymore. And best as I can tell, Trump has yet to answer the question that is at the heart of the system:

How do you provide insurance at a reasonable cost to higher-risk Americans (e.g., older Americans, people with prior illnesses and people who take medicine every day) if you don’t have lower-risk people (the young and the healthy) in the pool as well?

The reason for the mandate (or tax, or whatever you want to call it) that requires all individuals to have insurance is to make sure the pool is not skewed so far in the direction of high consumers of health care that it is impossible for anyone but Trump’s Cabinet to afford the premiums.

When I studied taxes in law school many decades ago, one of the first things we learned was that tax deductions are actually tax expenditures: Money that would otherwise go to the government doesn’t, making it no different than if the government were to spend that amount of money.

The Treasury Department takes the hit for the full amount of a tax credit, so we’re paying for that insurance every bit as much as we would be if we paid the private insurers directly.


And if you make the tax credit “refundable,” as some Republicans are proposing (because they recognize, rightly, that the credit alone might not convince people who already pay little or no taxes), then the Treasury not only eats every dollar spent by people who do pay taxes but also has to mail refund checks to cover the cost of insurance for people who don’t pay taxes.

Even more brilliant.

And even then, there is no guarantee this costly expenditure will lead enough of the young and healthy to buy insurance so we can keep the very popular parts of Obamacare without premiums going through the roof.

Because if you look at the polls carefully, while you can certainly find a majority that are against the Obamacare “tax” and “mandate,” you can find even bigger majorities who support banning insurers from excluding people based on pre-existing conditions (whether gastritis or cancer) and who favor the provision allowing parents to keep children on their policies until they are 26.

Be careful what you wish for. If premiums skyrocket and people find they can’t even buy insurance, nobody will blame Obama for messing up Obamacare.

And if the Republicans, having made this their central complaint for the last two elections, now drop the ball and do nothing, Trump won’t easily tweet his way out of it.

In the meantime — just in case — be well.

Susan Estrich is a best-selling author, the Robert Kingsley Professor of Law and Political Science at the USC Law Center and was campaign manager for 1988 Democratic presidential nominee Michael Dukakis. Click here to contact her or click here to read previous columns. The opinions expressed are her own.

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