Paul Krugman: Trump and Vance learned nothing from Obamacare

Donald Trump was rightly ridiculed for his response, during his debate with Kamala Harris, to the question of whether he had a health care coverage plan that would replace or improve the Affordable Care Act: “ I have ideas for a plan. He’s been running for president or sitting in the White House for nine years, and that’s all he’s got?

But the other day, JD Vance, his running mate, gave us a little more insight into these concepts – concepts that, if implemented, would result in millions of people being deprived of health care. Americans, especially those who need it most.

On Sept. 15 on “Meet the Press,” Vance — after emphasizing that healthy people have very different needs than those with chronic illnesses — called for deregulation, saying we should “promote more of choice in our health care system and not having a one-size-fits-all approach that places large numbers of people in the same insurance pools, in the same risk pools.

It’s unclear whether Vance was laying out a real vision for health policy or simply proposing his own plan concepts. To my ear, however, these remarks from Vance – who is closely associated with Heritage Foundation President Kevin Roberts, one of the architects of Project 2025 – sounded like this light-hearted statement from the Project 2025 manifesto:

The federal government should focus its reform on reducing the burden of regulatory compliance, unleashing innovation in health care delivery, ending interference in the daily lives of patients and providers, allowing alternative insurance coverage options and returning control of health care costs to patients who make decisions with their providers. about their treatment and health care services.

Vance’s remarks were bad either way. Apart from anything else, he seemed like someone who is completely ignorant of the history of health care economics and why we ended up with the policies we have – someone who completely missed the debates that led to the creation of the ACA, aka Obamacare.

We don’t need to speculate about how his proposal, such as it is, would work, because we’ve seen that movie; This is exactly how health insurance worked before Obamacare took effect in 2014, after which insurers were no longer allowed to discriminate on the basis of medical history. Under the pre-Obamacare system, insurers often refused to cover Americans with pre-existing health conditions or required them to pay very high premiums – which meant they were effectively denying health care, in many cases. , to those who needed it most.

Oh, and attempts to take care of Americans who couldn’t get private insurance, usually through the creation of special government-subsidized high-risk pools, have been abject failures: unaffordable, underfunded, and ineffective. covering only a small fraction of those who need help.

But wait, you say, before Obamacare, didn’t many Americans, including some with chronic health problems, get health coverage through their employer? Yes, they did and still do, but employer health insurance itself is largely the result of government regulation. Specifically, employers have an incentive to provide health care coverage because contributions to health plans, unlike direct payments to employees, are not considered taxable income, amounting to a large implicit subsidy for coverage. based on employment. But to qualify for this tax exemption, an employer-provided health plan cannot discriminate on the basis of medical condition or disability.

So placing people with different health states in the same risk pool – in effect, getting healthy people to subsidize unhealthy people with the help of taxpayer dollars – is, one might argue. say, the American method. In fact, one way to think about the ACA, with its ban on medical discrimination and its federal subsidies to help people pay premiums, is that it more or less introduced into the individual market the same rules that already applied to employer-based coverage, where people buy their own insurance.

One benefit of this expansion, by the way, was that it reduced job lock-in, in which Americans with health problems feared leaving employers that provided health insurance.

Now, one might ask why healthy Americans should subsidize sick ones. One answer is that healthy people today could be sick tomorrow. But beyond that, even relatively conservative Americans tend to believe that an element of social justice is at stake, that a wealthy nation should not abandon millions of its citizens who have health problems that corporations insurance do not want to deal.

Polls show that protecting people with pre-existing conditions is one of the most popular features of the ACA. According to the health policy organization KFF, two-thirds of the population – and half of Republicans – say maintaining this protection is “very important.” Unfortunately, polls also suggest that many Americans have forgotten the bad old days, with only a minority realizing that Obamacare banned medical discrimination that was once pervasive.

Yet why would Vance take such an unpopular stance, giving the impression that he was also speaking for Trump?

As I said, I don’t know if he was letting slip in public what the supporters of Project 2025 were saying in private or if he was just speaking out on an issue that he didn’t really care about. thoughtful. Of course, these explanations are not mutually exclusive.

Regardless, even if Trump doesn’t have a health care plan, Vance’s remarks offer a pretty good preview of what he will propose if he wins. It could be summed up, to borrow from the famous old Daily News headline, as “Trump to Sick Americans: Drop Dead.”

This article was originally published in the New York Times.