|At Valero Gas Station, Booneville KY/David Stephenson, Miami Herald|
What does it mean to be uninsured? I was recently uninsured due to bureaucratic ineptitude (don’t ask) and spent a day in the emergency room being treated for dehydration. I showed up at 9:00 a.m., had my blood pressure taken, conferred with a doctor, had attentive nurses keep an eye on me, was wheeled to an MRI examination to rule out anything serious, had a urine catheter, and was discharged by 3:30. Two weeks later I received a bill for $9,000.00. To be uninsured means to pay this bill out of pocket, and if we can’t, to be hounded to penury by bill collectors.
My insurance issues will be sorted out, and I can afford the treatment I received. But for 30 million Americans who remain without insurance in this country (2015), a $9,000 visit to the emergency room, is something they cannot afford. They will be hounded to penury by bill collectors. Getting sick without healthcare leads to suffering and death.
Nearly 30 million uninsured is more than the population of Texas; nearly the population of California. It is nine percent of our population. With Trump and Republicans in Congress set to make angry and reactionary changes to our health care system ("out of sheer spite" says Kevin Drum), the number of uninsured will increase again. Depending on the exact nature of the assault on state supported health care to be taken by Congress and the Trump administration, the number of uninsured may soon be back up to 50 million, or 15 percent of the population; i.e. what it was before the Affordable Care Act (2010) became law.
Do Republicans and Trump care about the plight of these uninsured? Consider this characterization of the GOP/Trump model for healthcare by Duncan Black at Eschaton (h/t Brad DeLong):
[T]he conservative plan for health care is "if you can't pay for it, you suffer and then die." This could be modified slightly to setting up a system by which your income is garnished for the rest of your life to pay for your treatment (not so different than what we have now, except with more pressure to actually treat people), or with a system that forces you to buy shitty health care insurance that you can't afford and which won't cover treatment anyway (ACA does this to some, though with health care that isn't entirely shitty and which might actually cover you).
That's how it is, and anyone who pretends otherwise is stupid or lying.
Most of the uninsured, approximately 24 million, are citizens; approximately 6 million are non-citizens, mostly undocumented workers. See Kaiser Family Foundation “Key Facts about the uninsured” (Sept. ’16).
Eight in ten of these uninsured are from low to moderate-income families, meaning they earn less than 400% of the poverty level. In 2015 the federal poverty level for a family of three was $19,078. Median household income in 2016 was $52,000 (meaning 50% of households in the country get less).
Families making less than the median income can’t afford the cost of health care on their own. The average cost of a family health insurance plan in 2016 was $833 per month ($10,000/year), with an average deductible of $8,000. If any member of a median income household has a visit to the emergency room like I had—a routine thing—they are out of pocket $18,000 for health care for the year. The real cost of health care in the United States today is beyond the means of nearly half the country.
So how do we manage?
Employer Sponsored Health Plans
Approximately half the population (49% in 2015) is covered by employer sponsored health care plans. It’s a World War II-era tax quirk, explained Ezra Klein back in 2009: The Roosevelt administration had instituted price controls to prevent profiteering; excess profits were taxed at (very) high rates. “At the same time wages were frozen so employers couldn't offer raises. But the government decided to exempt health benefits from these rules. So corporations took their wartime profits and plowed them into health care benefits. In 1953, with the war over, the IRS tried to overturn the rule. Congress overruled the IRS.” And ever since, employer sponsored health plans have formed the backbone of our health care policy. The ACA built on this structure by mandating that employers with more than 50 employees must provide health care coverage for their workers and dependents.
Trump and the GOP want to do away with the employer mandate.
Today one in five (20%) of the population are covered by Medicaid, a joint federal/state program for poor people.
Prior to 1965, we had no public health insurance program. Medicaid was introduced as part of President Johnson’s Great Society programs. Administration of the programs is up to the individual states (e.g. in California, the program is known as Medical). Although Medicaid is the largest source of government funded health care for people under 65 years of age who are unable to afford health care, eligibility is not easy. Prior to the Affordable Care Act (2010), eligibility in most states was restricted for persons far below the federal poverty level (e.g. Alabama 18%, Florida 33%, Georgia 37%, Idaho 26%, Kansas 38%).
With the ACA, Congress sought to reduce the number of uninsured by expanding eligibility under Medicaid to 138% of the poverty level. This was intended as a nationwide program, but under the Supreme Court’s holding in National Federation of Independent Businesses v. Sibelius 132 S.Ct. 1232 (2012), individual states were given the option to opt out of the ACA’s Medicaid expansion. Nineteen states have refused to provide this expanded coverage for their citizens who cannot afford health care insurance. These states have done so for ideological reasons (or spite, as Drum suggests); they have failed to adopt the Medicare expansion despite the fact that most costs would be borne by the federal government. Texas, for example, has refused to opt into the ACA Medicaid expansion and as a result 4.6 million Texans (17% of the population) is without health insurance.
Here is a Commonwealth Fund Report on the situation in Texas:
In Texas, Medicaid is available only to people with disabilities who have incomes below 75 percent of the federal poverty level (under $9,000 a year for an individual); pregnant women with incomes less than 200 percent of poverty (about $23,500 a year); and parents with incomes less than 19 percent of poverty (just under $5,000 a year for a family of four).
To the nearly five million Texans who can’t afford health coverage and who don’t fall into the above restricted categories, the state of Texas says “suffer, then die.”
Here is a Kaiser Family Foundation report, generalizing for the 19 states that have turned down the Medicaid expansion of the ACA: “Medicaid eligibility for adults in states that did not expand their programs is quite limited: the median income limit for parents in 2016 is just 44% of poverty, or an annual income of $8,870 a year for a family of three, and in nearly all states not expanding, childless adults remain ineligible.”
President Trump and the Republicans in Congress aim to do away with the expanded Medicaid coverage provided by ACA for all. They want to make everyone like Texas. Eighteen million who now have coverage under the ACA stand to lose their health coverage. “Suffer, then die, we have a political point to make,” says the GOP. The GOP’s political ideology is an ugly and callous thing.
ACA Subsidies for Individual Health Care
The ACA also provides subsidies for those earning in excess of 138% of the poverty level up to 400% of the poverty level (i.e. up to $47,520 for an individual). As of March 2016 9.4 million (2.9% of the population) received payment subsidies on the individual health care plan exchanges established by the ACA.
Subsidies are based on a Silver Plan in the area where you live. Silver plans are not cheap. For example, my wife and I pay $1,951/month for a Silver Plan in San Francisco. The maximum annual out of pocket deductible is $2,500 per individual. Our premiums ($23,412) and maximum out of pocket costs ($5,000) could add up to $28,412 per year. We don’t qualify for a subsidy, but if our income were up to 400% of the federal poverty level ($64,080 for household of two), most of the premium would be paid by the federal government under the ACA. The amount we would have to contribute would be a percentage of our income--2.04% to 9.69%--depending on income up to $64,080. In other words, if we earned exactly $64,080 (400% of federal poverty level), we would pay 9.69% of our income ($6,209) of the $23,312 premium, and the federal government would pay the balance ($17,103) of the premium. Our maximum exposure for medical care would be our share of the premium ($6,209) plus the deductible ($5,000), i.e. $11,209.
With the ACA subsidy, a medical expense of $11,209 on an income of $64,080, is manageable even if you don’t have significant savings. Not comfortable, but manageable. But the GOP wants to do away with the ACA premium assistance subsidies. Without a subsidy, my wife and I would be liable for the entire premium ($23,312) and deducible of $5,000, whether we earned $20,000, $30,000, $64,080, or more than that. No matter our income, my wife and I can afford this because we have sufficient assets saved over 40 years of working. But consider this: the median net worth of Americans aged 55-64 is just $140,000; the net worth of the 30th percentile in that age group is $40,000.
Annual medical costs of $28,312 would wipe out all savings of most people in the 55-64 year old age group in a very short time. “Suffer, then die,” say Trump and the GOP.
Medicare, enacted in 1966, is a single payer national health insurance program administered by the federal government that covers everyone 65 years of age or older who has worked and paid into the system through payroll taxes, as well as some younger people with disabilities, or certain specified diseases. In 2015 it covered 14% of the population (45 million over 65 years of age, and nine million with disabilities or qualifying disease). Speaker Ryan is making noises to change Medicare as we know it, but I'm guessing this is a bridge too far even for this Congress.
Other Insurance Programs
Approximately two percent of the population, primarily veterans and their dependents, are covered by special programs like that administered by the VA.
As of 2015, nine percent of the population was uninsured (nearly 30 million). If Trump and the GOP follow through with substantially dismantling the ACA, this will again rise to 15% of the population (~50 million).
“Suffer, then live in penury and die” vs. "provide comprehensive medical care to all without causing financial devastation as a matter of right." It’s what’s at stake for half the population, it's what's at stake for the soul of this country.
Whose side are you on?
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