3 March 2016 | 8:30 am
The Republican debates have included very little discussion of health care policy. But the issue has roared back into the conversation, and is likely to come back again at the Detroit debate on Thursday.
The Republican field is united in wishing to repeal the Affordable Care Act, the 2010 law known as Obamacare. But the remaining candidates have not developed detailed proposals about what would come next, though they have less comprehensive ideas that they speak about on the stump. Here’s our look at a few favorite talking points and how well they match up with the evidence. All quotations come from last week’s debate in Houston.
More Americans die of preventable illnesses than residents of many other Western countries. But very few of them die in the street. Or on the sidewalk.
Hospitals used to be able to turn away patients when they faced life-threatening emergencies, but Congress did away with that right in 1986, when it passed the Emergency Medical Treatment and Active Labor Act, known as Emtala. It said that any hospital that accepted Medicare dollars (that’s nearly all of them) also had to treat patients with an “emergency medical condition” without regard for those patients’ ability to pay. As a result, patients who are really sick can get emergency treatment right away — and that was true for decades before Obamacare.
Republican politicians have long used the existence of this law as an argument against hastily expanding health insurance coverage when they have objected to a policy proposal’s details. In 2007, President George W. Bush defended his veto of a bill providing health insurance for low-income children by saying that “people have access to health care in America,” adding, “After all, you just go to an emergency room.” In 2012, Mitt Romney made a similar argument while arguing for the dismantling of Obamacare.
The idea of a policy to prevent deaths in the street proved somewhat controversial in last week’s debate. But even if Obamacare is repealed, and nothing replaces it, the death of Americans on streets is not a major policy concern. People with chronic health conditions that require continuing care — say, cancer or diabetes — are the ones who struggle more to get health care when they lack insurance. The uninsured also face a high risk of financial calamity when there’s a medical emergency, even if they can get treatment. A gunshot victim without insurance will get care in a hospital, but the hospital is still likely to come after that person for the bill.
Mr. Cruz’s argument is confusing because the United States already has socialized medicine for the elderly: Medicare. Nearly every American over the age of 65 qualifies for the government program. There are some services that Medicare doesn’t cover, and in some cases, patients may have to wait to get a doctor’s appointment or a surgery date, just like Americans with any other insurance. But the Medicare program itself does not decide which people should get services like hip replacements first and who should have to wait. Indeed, patients in Medicare typically have faster and more equal access to health care than nonelderly adults in the United States, because they have universal insurance coverage and Medicare is widely accepted by doctors and hospitals.
Mr. Trump repeatedly hammered this idea last week, but eliminating state regulations on health insurance is not his idea alone. Mr. Rubio and Mr. Cruz also feature it as the centerpiece of their health reform platforms.
It’s a plan that is likely to have only a marginal effect on the cost and availability of health insurance. The main reason health insurers offer their products in one place and not another is the difficulty of making deals with doctors and hospitals in new markets, not compliance with local regulations. And without such contracts, it’s hard for insurers to offer attractive, national plans. No New York customer will want to buy a Utah plan that only covers Utah doctors and hospitals, for example. Before Obamacare, several states had already opened up their borders to out-of-state carriers. A 2012 study found zero takers.
Several of the candidates regularly assail Obamacare as a job-killer, but the evidence to support the assertion is weak. There are a few basic theories about how the health law might hurt employment: Poor people might choose to work less in order to qualify for income-based health insurance assistance; full-time workers might choose to go part time if they can get health insurance outside their job; companies might hire less if they are forced to provide expensive health insurance to their workers. But the early evidence suggests that these effects, if they are happening at all, are marginal. Over all, job growth has been strong since the law’s main provisions kicked in in 2014. And a pair of academic studies that looked at the subsets of the population most likely to be affected by the law show steady employment despite the policy changes.
It’s complicated. Over all, Mr. Trump is right that the country’s largest insurers have seen their market share and their stock performance grow since the health law passed. But other health insurers have taken big hits or gone under. “Some organizations have done really well, and others have been wiped out by all the change,” said Dan Mendelson, the president of the consulting firm Avalere Health. The most visible part of Obamacare — the new individual insurance markets in every state — have not proved profitable for many insurers. The law has also regulated industry profits, bringing down earnings from some lines of business. But other parts of the insurance business have flourished under Obamacare, particularly private plans sold to states for residents covered by Medicaid.
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