On health care, Republicans are about to give Americans more ‘skin in the game.’ And they’re going to hate it.

For the past eight years, Republicans have had the luxury of opposition, which enables you to blame anything and everything on your opponents without being burdened by the responsibility of coming up with your own solutions or being held accountable when things don’t go well. Now, of course, all that is going to change. And nowhere will their new situation be more vividly apparent than in health care, where they are determined to dismantle the Affordable Care Act yet can’t seem to agree on what they’ll replace it with. However it plays out, the country will get an extremely edifying instruction in conservative values as they relate to health care. And they’re probably not going to like what they see.

But first, here’s the latest news from the health-care front, which is that Americans hate the ACA so much that they’re signing up for it in droves:

About 6.4 million people have signed up for health insurance next year under the Affordable Care Act, the Obama administration said Wednesday, as people rushed to purchase plans regardless of Republican promises that the law will be repealed within months.

The new sign-ups — an increase of 400,000 over a similar point last year — mean the health care coverage of millions of consumers could be imperiled by one of the first legislative actions of Donald J. Trump’s presidency. Hundreds of thousands of other people who took no action will be automatically re-enrolled by the federal government in the same or similar plans, officials said, and their coverage could be threatened as well…

But the 6.4 million signing up on HealthCare.gov through Monday could undermine the argument that the law is in free fall. The five states with the most people enrolling for coverage on the site through Monday were Florida, with 1.3 million plan selections, Texas (776,000), North Carolina (369,000), Georgia (352,000) and Pennsylvania (291,000). Mr. Trump carried all those states.

That’s just people signing up on HealthCare.gov, which doesn’t include the states that run their own exchanges, people on Medicaid (12 million of whom stand to lose coverage if the law is repealed) or any of millions of other Americans who are threatened by repeal. That gives you a taste of the magnitude of the chaos and suffering that will ensue if Republicans go ahead with their repeal plan. But I want to point to a heartwarming story that shows us how values get expressed in policymaking, starring Rep. Bill Huizenga (R-Mich.):

The father of five offered a personal example of how this shift might play out. He says his youngest son fell and injured his arm. Not sure if it was sprained or broken, he and his wife decided to wait until the next morning to take the 10-year-old to the doctor’s office, instead of going to the emergency room that night. The arm was broken.

“We took every precaution but decided to go in the next morning (because of) the cost difference,” Huizenga said. “If he had been more seriously injured, we would have taken him in. … When it (comes to) those type of things, do you keep your child home from school and take him the next morning to the doctor because of a cold or a flu, versus take him into the emergency room? If you don’t have a cost difference, you’ll make different decisions.”

Rational health-care consumer or cruel parent? You decide. The point, though, is that Huizenga was acting just as Republicans would hope. For years, they’ve been saying that if we force people to have more “skin in the game” — i.e. more of their own dollars at stake in individual health-care decisions — then they’d become smart shoppers and drive health-care costs down. As one Republican plan was described in 2014, “If people are spending more of their own money, many conservatives argue, they’ll be smarter consumers. Overall costs will come down, the argument goes, if consumers have more ‘skin in the game.’ “

Trump has vowed to ‘repeal and replace’ Obamacare. Here’s why it won’t be so easy.

Play Video1:52
Donald Trump has campaigned to repeal and replace the Affordable Care Act, otherwise known as Obamacare, once he gets into office. Now that he’s won the presidency with a majority Republican House and Senate, that feat might not prove to be too easy. Wonkblog’s Max Ehrenfreund explains. (Daron Taylor/The Washington Post)

To take another example, one Republican governor accepted the ACA’s expansion of Medicaid only if, as one report explained, the state could “require beneficiaries to pay into health savings accounts. It’s based on the conservative principle that people should have ‘skin in the game’ as added incentive to stay healthy, and to discourage overuse of the health care system.” That state was Indiana, and the governor was Mike Pence.

But something interesting happened over the past few years. It turns out that people hate having skin in the game. When you choose a plan with lower premiums but higher deductibles, you’re giving yourself skin in the game. Which is fine if you never get sick or your kid never breaks his arm, but once something does happen, having skin in the game is terrible. Furthermore, shopping around for the best prices on health-care services can be really hard if not impossible (particularly in an emergency), so even when people have the ability to do it, very few do.

So as high-deductible plans have spread and insurers found new ways to pass costs on to consumers — a trend that started before the ACA passed, by the way — Republicans have responded with, “See? This is all Obamacare’s fault!”

But let’s be clear about one thing: Any plan Republicans come up with to replace the ACA is going to shift more of those costs and those decisions on to consumers. That’s because their goals in altering the health-care system are all about getting government out of the way — not expanding coverage and not protecting consumers, which are the Democrats’ main goals. There are some policy areas where the parties differ on means but agree on ends, but this isn’t one of them. Republicans are now saying that unlike the ACA, which sought to move toward universal coverage, they’re interested only in “universal access,” which is universal in the sense that access to BMWs and Rolex watches is universal.

You may remember how in the fall of 2013, a relatively small number of Americans insured through the individual market got letters from their insurers informing them that their old bare-bones insurance plans were being discontinued because they didn’t provide the minimum benefits required by the ACA. Republicans went positively bonkers with feigned outrage, and the news media helped their cause by offering up context-free portraits of these supposed “victims” without asking basic questions such as whether they might be eligible for subsidies in the new exchanges, and thus wind up with better, cheaper insurance.

Now take the number of people affected by that change, and multiply it by somewhere between 20 and 100 — and dramatically increase the harm that people will suffer. That’s what will happen when Republicans repeal the ACA. As we debate what they’re doing and what the effects will be, we should keep in mind that there are two fundamentally different value systems operating. Folks have to decide which one they think is more in tune with their own.


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