As Senate Republicans lurch towards repealing the Affordable Care Act, party leaders and the Trump administration are pushing a new line about the projection that their bill would strip 22 million people of their health insurance over the next decade: that many or most of those people would be exercising their freedoms and dropping coverage by choice.
“If you’re not going to force people to buy something they don’t want, then they won’t buy it,” House Speaker Paul Ryan (R-WI) said on Fox News. “So it’s not that people are getting pushed off a plan. It’s that people will choose not to buy something they don’t like or want.”
Ryan’s GOP colleagues in the Senate are doubling down on this argument even as the nonpartisan Congressional Budget Office and outside health care experts say it is largely the bill’s gutting of Medicaid, reduction of subsidies and increase in out-of-pocket costs that would price tens of millions of people out of the health care marketplace entirely.
Republicans are pointing to the CBO’s finding that 15 million people would drop their insurance in the first year the Senate bill would go into effect, arguing that immediate drop-off is a sign of widespread eagerness to go uninsured once Obamacare’s tax penalty is repealed.
Alice Rivlin, the founding director of the CBO under Presidents Ford, Carter and Reagan and the Director of the Office of Management and Budget under President Clinton, told TPM she disagrees.
“Without a mandate to buy insurance, we’d go back to it being fairly cheap for young, healthy people to buy it, but very expensive or impossible for older, less healthy people,” she said. “It’s not a choice if the cost is much higher.”
There is even less choice for those low-income people who depend on Medicaid and who account for two-thirds of the population that would lose coverage under the bill, notes Josh Peck, the former chief marketing officer for the Department of Health and Human Services.
“I can’t fathom how there’s a freedom argument to be made there,” he told TPM, pointing to the bill’s provisions that would eventually phase out the Medicaid expansion and greatly reduce spending on the program. “They’re literally taking away an option. There’s no way you can argue with a straight face that those millions of people are choosing to go without health care.”
The latest CBO assessment of the Senate’s bill makes that repeatedly clear: Yes, some people would choose to forego insurance, the report says, but that choice would be largely motivated by higher costs for even skimpier coverage.
“Without the mandate penalties, some people would forgo insurance in response to the higher premiums that CBO and JCT project would be charged,” the office writes.
It later notes that because of sky-high deductibles, higher premiums and smaller tax credits, “few low-income people would purchase any plan.”
The higher deductibles in particular, CBO notes, “would contribute significantly to a reduction in the number of lower-income people who would obtain coverage through the nongroup market under this legislation.”
As for the millions of people who could lose their Medicaid coverage due to the bill’s gutting of hundreds of billions of dollars from traditional Medicaid and its rollback of Obamacare’s expansion of the program, Republicans have argued that moving those people into the private health insurance market is a good thing for the country.
The CBO, however, calculated that even with tax credits, “because of the expense for premiums and the high deductibles” most of those who stand to lose Medicaid coverage would not purchase insurance.
Still more would be left uninsured when the bill’s passage leaves no insurers in certain areas. “Some sparsely populated areas might have no nongroup insurance offered because the reductions in subsidies would lead fewer people to decide to purchase insurance,” the office wrote.
Senate Republicans and the Trump administration are sticking to the rhetoric of “choice” and “freedom,” though, even as they pressure the CBO to give them more favorable numbers.
“There’s 7 million people they say will choose to leave the market that they say are losing insurance,” President Trump’s director of legislative affairs, Marc Short, asserted in a recent interview on “Fox News Sunday” about the latest CBO report. “That’s not losing, that’s choosing.”
Sen. John Cornyn (R-TX), the Republican majority whip and a major booster of the Obamacare repeal effort, has taken to social media to argue that the bill will give Americans the “freedom” to go uninsured:
Not lose, choose. Apparently you believe freedom is optional https://t.co/WIUJz2Mxv7
— JohnCornyn (@JohnCornyn) July 6, 2017
Sen. John Barrasso (R-WY), the fourth-highest ranking Republican in the Senate, made a similar argument to reporters, claiming “that the preponderance of the people who would not be insured were not actually losing insurance.”
“Because it’s a free country, they would choose, because we eliminate the individual mandate, to not buy insurance,” he said.
Peck, who oversaw the implementation of the Affordable Care Act’s insurance exchanges, says years of federal surveys and studies contradict these claims.
“Either they’re ignorant or they’re lying,” he said. “At HHS, we did a ton of market research, both of people on the exchanges and the eligible uninsured who weren’t on the exchanges. Our findings were that people overwhelmingly want health insurance, and their big concern was cost.”
A national poll by the Robert Wood Johnson Foundation found that just 26 percent of the uninsured said the individual mandate made them more likely to purchase health coverage. “Most of the uninsured population values health insurance but many see cost as a barrier,” the study concluded.