Oped: GOP health-care plan really about destructive ideology

Erika D. Smith
Tribune News Service

This week, just as the blowback over the House Republican plan to replace Obamacare was turning into a hurricane, a smug Rep. Jason Chaffetz went on CNN to try to sell the legislation's merits.

OIn this file photo, Heather Bradford, of Spring Garden Township, holds up her "Don't Kill Real Health Care Reform" sign, during the Indivisible York demonstration, Tuesday, Feb. 28, 2017, at Continental Square. Amanda J. Cain photo

Asked whether Americans would lose health coverage if Trumpcare passes, the Utah Republican pulled off an ideological deflection worthy of Ronald Reagan and his mythical "welfare queen."

"Americans have choices," Chaffetz said, starting down a path that Twitter has since likely made him regret. "And they've got to make a choice. So, maybe, rather than getting that new iPhone that they just love and they want to go spend hundreds of dollars on, maybe they should invest that in health care."

The exchange was revealing, to say the least. Too many in Republican Party seem hell-bent on governing by fiction rather than by fact.

It's now abundantly clear that no matter what House Republicans, including Majority Leader Kevin McCarthy, say about keeping their campaign promises and helping Americans get affordable health care, their replacement plan is really just about ideology. Destructive ideology, at that.

The insistence on passing legislation that would force millions of people to lose their coverage and cause what California Insurance Commissioner Dave Jones called a "death spiral" in the health insurance market is about more than just thinking the United States can't afford to subsidize services for poor people.

It's about a stubborn, frankly absurd belief that the nation shouldn't even try — not without strings attached anyway — because poor people are lazy and should make better choices to help themselves.

This is the type of twisted thinking that led Vice President Mike Pence to order up an experimental health insurance program when he was governor of Indiana, rather than just expand Medicaid under the Affordable Care Act. I was working in Indiana at the time, a state where thousands of people had long ago given up on getting health care. The lengthy fight with the federal government to get a Medicaid waiver seemed more like a heartless political point for Pence to score against Democrats than a sincere nod toward fiscal responsibility.

Three years later, it's a program that's being talked about as a national model for how other states can provide health care the "compassionate conservative" way.

Yes, Trumpcare could pave the way for Pencecare, even though the facts and some research dictate neither work as well as Obamacare. Gross, right? But how else can Republicans go about teaching all those lazy poor people the conservative value of personal responsibility?

Pencecare, officially known as the Healthy Indiana Plan 2.0, or HIP 2.0, requires recipients to pay an average of 2 percent of their monthly income to get coverage, no matter how poor they are. Even those with no income have to pay a minimum $1 a month.

If people miss a payment, they get bumped to a second-tier plan that requires co-payments to see the doctor and eliminates access to already modest dental and vision coverage.

The vice president would argue the program is a huge success. Indeed, there are some positives. More than 400,000 people have signed up for coverage, sending Indiana's uninsured rate south of 10 percent for perhaps the first time ever.

"There is something to be said for the dignity of empowering low-income Hoosiers to make their own decisions about their own health care," Pence said last year. "People stand a little bit taller."

Maybe. Or maybe their pockets are just a little bit lighter.

As it turns out, upon closer inspection, Pencecare isn't so much compassionate as it is conservative. Nonprofit agencies have admitted to paying the monthly fees for poor people so they don't lose coverage. In other cases, people have signed up for coverage, but haven't made the first payment so they are considered "conditionally enrolled," which looks good on paper, but doesn't quite accomplish the goal.

"It may look sensible on paper to penalize people who let insurance lapse or miss a premium payment, but in the real world it is cruel and counterproductive," said Fran Quigley, an old acquaintance who is director of the Health and Human Rights Clinic at Indiana University McKinney School of Law. "People miss or are late on insurance payments for a lot of good reasons: They need the money to pay rent or else face homelessness or to feed their families, they don't understand the often very confusing rules and deadlines involved, or the paperwork never gets to the right place.

"Punishing them by raising their rates or barring them from coverage causes real suffering,' he continued. "And it often ends up costing more for taxpayers, since these folks will often require expensive emergency services because they can't access preventive or chronic care."

None of this is surprising, given what studies have warned for years about the pitfalls of forcing people who have no money to pay to go the doctor.

But Pence is a man willing to double down on conservative ideology even when it makes little sense. And so is Seema Verma, who designed Pencecare and is now President Donald Trump's pick to lead the Centers for Medicare and Medicaid Services, which has oversight of Medicare, Medicaid and the Affordable Care Act.

So watch out if House Republicans manage to shove their replacement bill through Congress, defying criticism, and onto the president's desk.

Under the plan, gone would be the crucial subsidies that help poor people pay their deductibles, replaced by refundable tax credits meant to entice people to buy insurance on the open market. And starting in 2020, Medicaid payments to states that fund those tax credits would be reduced to undo the expansion of the entitlement program under Obamacare.

Squeezed financially, states would be forced to pick and choose how to fund health care, deciding which sick people to help and which ones to let fend for themselves. Some states might see little choice but to adopt a cost-sharing model similar to Pencecare. Ohio and Kentucky are already considering it.

In the end, though, no one will benefit from replacing the truth about health care with ideology. Sorry, Mike Pence, but making America great is not making America Indiana.

— Erika D. Smith is a columnist for the Sacramento Bee.