Why Are So Many Americans Worthless?

I wish the Republicans voted on whatever healthcare plan Donald Trump thinks they passed through the House of Representatives yesterday. In Donald Trump's mind, this bill keeps protections for pre-existing conditions (outright lie), still grants insurance to everybody (at least twenty-four million will lose coverage*), would offer "great healthcare" (his definition of "great" varies considerably from mine), and it’s going to lower healthcare costs (for the young and healthy only - maybe).

Typically I’m just an idiot on the internet, but the AHCA/Trumpcare/Ryancare is one of the few places I can actually speak with some level of expertise. Health insurance is my day job, I work as an Insurance Analyst for a healthcare provider. (Not my dream profession, but it pays.) So for once, I actually know what I’m talking about. Personally cutting Medicaid is really bad for the company I work for, since we need those plans to stay in business. But beyond that I can also tell you that the healthcare system in this country is a goddamned mess of epic proportions - the fact my job even exists is testament to that. RINOcare is not going to make things any simpler, just more chaotic and segmented.

The reality, of course, is that the bill guts Medicaid and creates a roadmap for its eventual death, gives wiggle room for states to opt out of pre-existing condition restrictions, allows insurers to bring back crappy plans that don't cover a whole lot, and deeply increases costs for the elderly. You lose if you’re poor, if you're sick, if you're old, and you'll even lose if you’re young and healthy because the policies you’ll now get are much worse than the ones you need. And this bill has brought everybody in the healthcare sector together... to oppose it. Hospitals are terrified of it, the AARP hates it, doctors don't like it, and even health insurance companies have spoken out against it. The only winners in the immediate term are the upper class, who will get lower taxes. The rest of us are losers.

The AHCA seems like a bill for nobody. So why would this legislation even be considered in the first place? Why do so many Americans simply not count in the eyes of their Congress?

Right now the modern health system is a miracle unprecedented in world history. You have a better chance of surviving illness and injury today than you ever had before. The issue is largely not access to care, the issue is affording that care. Because every one of us, no matter how young and healthy you are now and no matter how many trendy rooftop parties you take your Nintendo Switch to today, are ultimately doomed. You have a devastating health situation waiting for you in your future. Super great healthcare is super expensive. One day you will need hundreds of thousands of dollars' worth of healthcare to stay alive, assuming you're not lucky enough to get a nice quick and cheap death. You buy insurance to cover up the risk, so that when the worst happens - and it will - your life is not ruined forever by it. Do you want to be a million dollars deep in debt? Well imagine surviving cancer only to now live a life of financial destitution. Oh and you're a much bigger insurance risk too now, by the way. Car insurance is not optional, yet for some reason, healthcare, with far greater risks, to Republicans, is.

The fact of that matter is that healthcare in this country is an ad hoc jumble of a century's worth of legislation, that had serious problems in 2009. Technically we never had a healthcare system, just a bunch of things that developed anarchically into one. I never loved the final Obamacare bill and don't love it now, since without the public option, its a much weaker piece of legislation than we need. However, it did actually does a lot of good. Basically Obamacare raised taxes on the wealthy and forced everybody to buy insurance. We as a society pool our resources to make sure the poorest, worst off, and biggest users of healthcare are still covered by good insurance policies at a relatively affordable rate. The ACA doesn't work brilliantly, it's overly complicated, but there are much worse alternatives. Like say, Trump and Ryan's AHCA.

I hear a lot from Republicans that people are smart enough to take care of themselves. They don't need to be guided along by Obamacare. They can choose their own care and manage their own affairs. The problem with this is simple. Trust me, you're talking to somebody who knows, this is an ugly fact that most people won't admit: nobody really understands what their healthcare covers. Look closely at your plan, and I don't care what insurance you have, it isn't going to cover as much as you think. By next year after the AHCA comes around, when you have lifetime maximums again and you have to pay extra for basic things like hospitalizations, it will cover even less. Will you be paying enough attention to notice how much you'll lose?

Healthcare is massively complicated and very boring - by design. Insurance companies don't want you to really know how much you're buying. They want to cover as little as possible, so keeping it obtuse and dull is to their advantage. You pay a monthly premium, but then you have deductibles. Then the policy only covers so much. Then there's the issue of do you have an HMO or a PPO. Is your insurance from out of state? Which of your policies is primary for hospitalizations? Do you have dental? Have you paid your copay? Your coinsurance? Have you met your out of pocket max? Is the doctor you're seeing in or out of your network**? Donald Trump thought this was easy, that's the shocking thing. He wouldn't last a day in my job.

The bigger problem with this free will doctrine is that the people who most need healthcare are the ones least capable of managing their affairs. Great-grandmothers who have had Medicare since before I was born have no idea what their insurance is. The sick and dying can't negotiate with hospitals to keep their costs down. Who can haggle in this situation? You're not shopping around deciding if a plan with a lower deductible but higher premiums is more economical when you're bed-ridden.

And most importantly: freedom of choice is a meaningless argument anyway since the people worst affected by Trumpcare don't have that freedom. People don't choose to get Medicaid - they're dirt poor or disabled so either get Medicaid or nothing. (Not that Medicaid is bad, just the opposite in my experience.) The elderly are done working and barely get by on fixed incomes. And those with pre-existing conditions will take whatever they can get. The less the government is involved with healthcare, the fewer options all these people have. Also the chilling fact is that one day you too will be either elderly or sick or both, and if you're the first two, you'll probably be poor too soon enough. You will join this crowd whether you like it or not.

So healthcare isn't some rational system that self-corrects that doesn't need government intervention. That's a fantasy and a dangerous one. (We pay more in this country for far less than any other developed country. It isn't government intervention that's raising prices.) The question therefore is, do you want your healthcare system to function or not? Do the unfortunate deserve access to care or not?

There is a terrifying and cold logic, but at least it is a logic, to cutting access to healthcare to so many. The old are just getting older, the sick may never get better, and the poor might never be worth the investment. These are the weakest segments of society and thus the least productive.

The problem with this argument is the fact that it is largely psychopathic. Do you want to tell the poor they're not worth the trouble? Do you want to tell grandpa that he's already contributed all he can to the nation and now he's a net negative so do the patriotic thing and drop dead? Tell the sick that the Republican Party is so religious they believe Jesus will save them, so it's not our problem? I don't think the American people will go for it, but if that's what you believe, argue your case.

What is not logical is all the lies around the AHCA. Step by step this bill is all about avoiding the real idea, which is that the well-off are just worth more than the desperate.I want the Republicans to admit what this is all really about. Say the words: "we want to cut taxes for the wealthy because we think they are a better use of American money than healthcare insurance for twenty-four million people."

Say those words. Be honest. And we can debate why you're wrong. Instead the entirety of this bill's passage is not about clarity. Every step was avoiding the truth and more importantly, avoiding responsibility.

Donald Trump's claims around this bill read like he just instituted Bernie Sanders' plan of "Medicare for All". However he seems to have no interest in what's actually in this bill just as long as there is one. Credit where credit is due, Trump got the bill through the House, but he didn't work at all to make one that was anywhere close to what he's still promising. He's a pickpocket patting his own supporters on the back while lifting their wallets. But he's not even the most delusional in this crowd. It goes well beyond him.

Why are there so many reports of Congressmen not even reading the text of the bill? Why was the bill pushed through without letting the Congressional Budget Office score it and tell us what the real effects are? Why was the writing, amendments, and all discussion of the bill performed off the floor of Congress? Why couldn't there be any public discussion? Why does this all so hypocritical from a party that complained so much about these same things when the Democrats were in power in 2010?

The answer is simple: Republicans didn't want to know what this bill did. Then, some of these Congressmen went on to claim with absolute alacrity, while they drank their celebratory beers at the Rose Garden, that the Senate will fix the problems. They are literally passing the buck to the other chamber of Congress and cheering their success while they do it. These are lawmakers who don't actually want to make a law. They want somebody else to do it for them. That way there's somebody else to blame.

Avoiding responsibility is even written into the text of the Trumpcare bill. Massive cuts to Medicaid are here (going beyond even slicing out the Obamacare expansion) but it also passes most of the Medicaid management to the states. This is designed so that Medicaid will inevitably become underfunded, see less and less federal contribution, and ultimately become worthless. Or states will just go bankrupt trying to fund this thing, because they do not have the infinite borrowing power of the federal government. Other parts of the bill give states the power to destroy the some of the most popular Obamacare provisions. This means that Congress is just loading the chamber, it's up to the states to fire the gun. Technically it isn't Donald Trump or Paul Ryan who took away the insurance of those with pre-existing conditions, it was the governors. This is all in the name of "flexibility" for states. "Flexibility" is code for "We're leaving the states out to dry here, and if they're smart, they'll dump these Obamacare assholes".

AHCA only exists thanks to a massive conspiracy of dodging blame on all levels of the Republican government. Donald Trump let this bill be Paul Ryan's creature because he couldn't tell his base what this is really about. The House wants the Senate to "fix it", meaning frame them as the creators of the final disastrous version. (I have zero faith the Senate will at all improve this bill.) Congress wants it to be the states to actually cut programs. And the states will blame the insurance industry. I don't know who the insurance industry will blame at that point, but they'll find somebody. So it isn't Trump's fault, it isn't Congress's fault, it isn't the states' fault, it isn't anybody's fault! Everybody wins!

...by which I mean, a Hell of a lot of us lose here.

The Republican plan was never about improving health insurance for anybody. Death panels myths, "Obamacare is destined to implode", all the acrimony, all the lies, it was all just to make sure we can't invest in our people. It means that a certain segment of society doesn’t have to pay for the rest of it. Republicans don't even care about the size of the government or spending, just that the government spends on the right places. So we can have islands of success in a nation otherwise fading into third world status. This is wealth redistribution, that favorite boogeyman of Conservatives. But its redistribution from you and me to the wealthy. The Republicans claim they're making the game fair while cementing how hopelessly slanted the rules are, forever.

What Congress won't tell you is that the AHCA says that millions of people are not worth the costs. What happens to these people I don't know. But I do know that Republicans don't care. The "haves" get to still have and the "have nots" still have nothing. That's what the healthcare system is really about in this country. There was never any interest in fixing it on the Republican side. They only wanted to devour as much as they can for as long as they can.

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* We still don't have a score from the Congressional Budget Office on the latest version of the bill, so how many will be uninsured is unclear. The last version of the bill that got eliminated in March had twenty-four million, and that was actually a more moderate bill. You can expect the results of this one to be worse.

** It isn't Obamacare that keeps people away from their doctor, its private insurance networks. Medicare has no network. Its good essentially everywhere.