Trumpcare/BCRA Addendum

Several new items and thoughts occur about the Senate’s version of Trumpcare, titled the Better Care Reconciliation Act (BCRA).

First, it is wildly unpopular. More than 40 economists (some of whom are the most cited macroeconomics and health policy economists), including approximately 8 Nobel laureates to date have signaled official opposition. So, the economics of the bill is not good for the country. So too do religious persons have a problem with Trumpcare. The United States Conference of Catholic Bishops has denounced the bill, stating “these changes [that the BCRA promises to Medicaid) will wreak havoc on low-income families and struggling communities, and must not be supported.” Lastly, not even the American people want the bill. In other words, the bill has no economic, populist, or social justice merit. For whom, then, is this bill being produced for (and let’s be honest, we all know who)?

Two other points, however, are worth mentioning. First, Trumpcare exposes a phony belief behind all conservative reform attempts. As pointed out by Atul Gawande in the New Yorker today, Trumpcare proponents believe that health care is an activity one only pursues when sick.  Americans only seek health care when they catch pnuemonia, for example, or only when breast cancer symptoms are apparent. While this is certainly true in many cases, it is not exclusively true. The other way to practice healthcare is incrementally/preventatively. One pursues health in an incremental way by seeing doctors regularly, even if healthy. All Americans have had this experience; vaccinations before entering schools; physicals to qualify for athletic competitions; etc.. As Gawande notes, professional studies conclude that the incremental approach to health care improves health outcomes. Because so, Obamacare incentivized the incremental approach, encouraging Americans to maintain health and identify major problems before they become prohibitively expensive to deal with. The BCRA, however, potentially undoes such incentives by allowing states to waive certain requirements the ACA imposed on all insurers in all states, such as requirements for preventive services. With substantial evidence suggesting the benefit of preventive care, why not maintain that requirement of the ACA?

The second point is central to understanding the questions and concerns I raise about the BCRA above. Namely, the BCRA is less a repeal of Obamacare, and more a repeal of Medicaid. Not only is this point made by Gawande in the article linked above, but it has also been suggested by moderate/conservative commentators in recent days.  At its root, the comfort conservatives generally have about denying the poor and disabled access to care stems from a belief that a social welfare program such as Medicaid is unfair to those of us who pay for it (through taxes), but do not directly benefit from it. This ethos also usually holds that these social programs wasteful since they are run by government bureaucrats whose job is reliant on administering the program. No Medicaid, in other words, means no job for those in the federal government who work to administer the program. Hence, they abuse their position in the federal government in ways that make their job necessary. And as such, since Medicaid is funded through tax transfers, we the tax payer are essentially billed twice over: enough to pay the salaries of plan administrators, and medical services rendered to Medicaid recipients. These recipients would be better off with some tough love, they say, arguing that Medicaid creates dependency on the system by disincentivizing work (since they do not need to anymore to pay for their health needs).

The reality of Medicaid, however, is much different. First, Medicaid is not inefficient, billing the American taxpayer unnecessarily. Medicaid is instead more efficient than any private insurer currently operating. Secondly, Medicaid has been found to have no effect on labor force participation, positive or negative (nor does it increase use of other welfare programs, such as SNAP). Instead, the majority of Medicaid recipients work, with only those recipients who are disabled or elderly accounting for the majority of Medicaid recipients not working. When one recognizes that Medicare, the other social insurance program Americans have access to, is similarly more efficient than private insurers, many of the claims against federal programs for reasons of inefficiency and dependency fall flat.

I would argue instead that these social welfare programs are an important pillar to maintaining a dynamic economy. As I argued in another post, healthy workers are more productive, and a strong system of social insurance helps allocate our labor force to those domestic industries more easily (for a good and complementary argument to my own, see here). But even if you do not accept that this is a benefit in reality, or a benefit worth pursuing, surely those arguments typically made against Medicare cannot also be acceptable.

That would mean that all we are left with is what is “fair,” and though I certainly have strong opinions about what I think is “fair,” they are highly subjective, as would be any discussion of fairness. But since that is the case, let us proceed on those terms, and not the current disingenuous ones described above.

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