My Conversation with a Republican
By Janlee Wong, NASWCA Executive Director
For several of my columns since last November’s election, I’ve encouraged conversations with Republicans, particularly Trump supporters. Based on a National Public Radio interview with Senator Ron Johnson (R-Wisconsin), I’ve constructed the following imaginary conversation on health care.
WONG: What about the 22 million people that the Congressional Budget Office (CBO) estimates will lose insurance coverage due to the version of Senate healthcare bill that was released June 22.
JOHNSON: … the 22 million people you’re speaking about, the CBO estimates will—or estimates will no longer have coverage. Fifteen million in 2018 would be uninsured–and this is an exact quote—primarily because the penalty for not having insurance would be eliminated.
WONG: In other words, 15 million would drop their coverage in 2018 because the mandate to have insurance would be eliminated. Who would cover these 15 million if they need health care and can’t pay? What about the other seven million who had their coverage dropped because of this bill? How would people with pre-existing conditions be covered if their insurance is dropped due to the mandate being dropped?
JOHNSON: Well, first of all, you can actually cover people with preexisting conditions without class insurance markets. Wisconsin had a pretty effective high-risk rule. Maine, when guaranteed issues when their premiums doubled, instituted something called an invisible high-risk pool and pretty well cut those premiums in half. So, there’s a way of doing this without collapsing insurance markets.
WONG: High-risk pools depend on adequate funding. Since states would be responsible for funding these pools, those that have tight budgets would mostly likely underfund it and cause people with preexisting conditions to have inadequate insurance or to lose coverage. The legislation wants to cut Medicaid severely and cap (block grant) it. Won’t millions of poor people who can’t afford insurance become uninsured?
JOHNSON: Now, what I’m concerned about is we’re $20 trillion in debt. Over the next 30 years, according to the Congressional Budget Office, we’ll accumulate another $129 trillion worth of deficits because of these entitlement programs that are unsustainable. They’re out of control.
We’re trying to devolve the management of things like Medicaid back down to the states where it will be managed more efficiently, more effectively, more tailored to individual states because every state is different.
WONG: Many states are saying they need money to operate Medicaid without cutting recipients. No matter how efficient they are, they can’t provide Medicaid if they don’t have sufficient funding, which the bill is cutting. How do we control continuously increasing premiums that were increasing before, during and probably after Obamacare?
JOHNSON: We need to be looking at primarily—what do we need to do to restrain the growth in health care costs which have been driven up because we’ve largely driven consumer-driven free-market competition out of health care.
WONG: Wasn’t the free market competition concept to control costs behind Obamacare exchanges?
JOHNSON: So when you actually have consumers directly purchasing things, they will demand the price. They’ll put a great deal of pressure on providers to have the lowest possible price, the best quality, best, best, best possible customer service. That’s what free-market competition does in every other area of our economy where it exists. We’ve largely driven the benefit of that free-market competition out of medicine, and we’re not happy with the results.
WONG: I believe that was what was happening with the California exchange, but premiums kept increasing. California provides Medicaid through managed care plans but that hasn’t reduced costs. If Medicaid recipients were to directly purchase their health care in the open market, would they have sufficient income to do so? Wouldn’t they need a subsidy? You’re asking for more time to improve the bill, right?
JOHNSON: Well, first of all, what I want is just a little bit more time. I’m not asking months, but I think it’s ridiculous to be voting on it this week, you know? Let me make my case to the White House. I don’t think our case has been heard by the Senate. So, I’m just asking for some time to work with the White House and our House members…
WONG: Yes, more time is needed. Especially to address of the concerns I’ve raised in our conversation today. That’s something we can agree on.