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Why We Make Laws: Policy and Implementation and Trumpcare

I’m still hoping to do something drastic like drink whiskey while reading this new Trumpcare bill (tagline: “Like the House bill, but now needing Ted Cruz’s vote”). But that will have to wait while I’m up at 30,000 feet.


Laws get written for a reason – a policy reason. The person writing it, or their constituents, have some objective they want to achieve, something they want to change. Limited access highways would improve the economy: Interstate Highway Act. People want to preserve some truly special parts of the country: creation of the National Park System. These are policies. With a policy goal in mind, the language of the bill does something to make it happen. Allocate money or people, organize, regulate or de-regulate, or do any of the things on the list of things that can be done. This is implementation. We can define a “good law” as one that has a valid policy objective and implements changes in a way to make the policy a reality. You and I might disagree on what the right policies are or how to implement them, but hopefully we can agree that this is what legislation – what governing is.

Let’s look at the Affordable Care Act. Policy goal: make insurance available without exclusions or denials for pre-existing conditions. Implementation: Guaranteed Issue and Community Rating. Policy goal: prevent death spiral due to only sick people buying insurance. Implementation: Individual mandate. Policy goal: make insurance more affordable for people below (roughly) median income. Implementation: Subsidies, paid for by taxing (mostly) the top 2% of earners. Policy goal: get more people on insurance, in any way at all. Implementation: the above, plus Medicaid expansion, Basic Health Plans and more. Say what you will about the Affordable Care Act, but it has had a lot of success at achieving its stated policy goals: the implementation worked. The metrics for these policy goals could be better, but they have all improved in the last seven years, directly because of the ACA.

Then I look at this new thing from Mitch McConnell, which is apparently called the BCRAP? And I ask myself, what are the policy goals here? What is wrong with the health system in this country that it is attempting to fix?

“Repeal Obamacare” – I mean OK, I get that this has been a mantra for a long time, but that isn’t a policy goal. And if it was, you could implement it by – hold your breath here – repealing Obamacare. This bill doesn’t do that. If anything, it takes the body of Obamacare, tears off the meat and leaves the skeleton with a bit of rotting flesh. This bill is Obamacare after a vulture attack.

The biggest complaint about the system from people seems to be higher out of pocket costs. Leaving aside that out of pocket costs are equivalent to that skin in the game that the GOP seems to love, reducing these are at least a valid policy goal. Some Republicans have said that they would like to do this. But there is literally nothing in this bill that would implement this policy! In fact, it includes specific provisions that would allow them to go higher. They could even become uncapped again.

Lowering premiums is also a valid policy goal. Now – premiums mean different things to different people. Are we talking before or after subsidies? And let’s be sure we compare like product to like – a bagel is cheaper than comprehensive health insurance, but I wouldn’t call swapping my BCBS plan for a sesame toasted with scallion “lower premiums” even if the sticker price was less. In any case, this is another policy goal – but again, nothing in this bill accomplishes it! With the mandate gone, unsubsidized premiums will go up 25% more than they would have otherwise. There is nothing in here about cost controls – nothing about negotiating prices lower by using rates closer to what Medicare/Medicaid pay. Under the ACA, insurance companies are limited in what they charge by (among other things) a requirement to spend at least 80% of premiums on actual patient care. That provision is, of course, repealed in Trumpcare. How does that lower premiums?

Protecting people with pre-existing conditions – Trump and Ryan and McConnell and whoever like to say that they are protected in this plan. But this just isn’t true. The ability for states to get waivers will allow states to decimate the protection that came from the ACA. How many states will take the waivers? No idea – the CBO guessed 1/6th of the population would live in waiver states, and that insurance markets there would largely collapse. If you want to protect people with pre-existing conditions – why do this at all? The best case is that states stay with the Obamacare regulations in the first place.

They might say that repealing the individual mandate is a goal in and of itself, because “freedom.” But this is a stretch – the mandate is just the implementation of other goals that the ACA had, as discussed above. Maybe your policy goal is “make it so that people are no longer forced to buy insurance.” Ok, I can grant as at least coherent, and it is implemented here. But have you ever met somebody who had insurance but said “I wish I didn’t”? I haven’t – they complain that the premium is too high, or the copays and deductibles are too high, or it doesn’t include their doctor – but never the actual insurance. Why? Because they know if push comes to shove and they have a major medical issue, getting true comprehensive treatment for them or their families is difficult or impossible without health insurance. Oh, and it usually leads to bankruptcy if you can get it.

Republicans often say that the number of insured is not a valid metric. I’ve never quite gotten the logic there – again, people understand the reason why having insurance insures them in the case of the worst health situation. In any case, they certainly didn’t implement greater coverage: whatever you think will happen in the individual market, Medicaid cuts will massive decrease the care available to the poor, young, old and disabled. There is nothing in this bill that will do anything to help those kicked off of Medicaid to get coverage anywhere. Maybe “increase the number of uninsured” is the policy goal? They did a fine job of implementing that.

Of course, this Trumpcare has tax cuts. They are the one thing that is implemented in there, black and white. Implemented right to the top 1%, 2% of earnings. Implemented retroactively – so that we can encourage them to make investments they’ve already made?

Why, it’s almost as if giving tax cuts to the richest amongst us is the only real goal of this “health care bill.”


Note: This idea is riffed off of this article on Vox. Then, as I was getting ready to publish, they hit the button first on something eerily similar to this. Damn those Vox guys!

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