The United States is about to become Russia’s best friend and at least a silent ally of Syrian strongman Bashar al Assad, and President-elect Donald Trump plans to build only a little of that wall and over time ship back no more than a couple of million illegal immigrants (the crooks, he says), fewer than President Obama. But none of that is likely to affect little Arkansas very much, but what he does on one of his promises will have huge impact, potentially.
A week after his surprising election, Trump has sent some signals that has to be encouraging to the 400,000 or so Arkansans who will be deeply and very directly affected if he keeps his promise to join Congress in repealing the Affordable Care Act, aka Obamacare. The signals ought to provide some relief as well to Gov. Asa Hutchinson and the knowledgeable members of the legislature who will be confronted with insoluble budget problems if Obamacare is scrapped and nothing done to replace it. They have never been able to say that because it would be fatal to say something benign about Barack Obama or the Affordable Care Act.
First, the Trumpian signals. After meeting with President Obama, he said he wanted to retain some key features of Obamacare, especially the mandates that insurance companies cover people with pre-existing conditions without penalty and that allows offspring to stay on their parents’ policies until they are 26. Polls show those are universally cheered, unless Obamacare is identified as the source. Forbidding insurance companies from cutting off people when they get acutely sick or refusing to cover them at regular premiums will drive up everyone’s insurance premiums, unless the industry gets to keep some other features of Obamacare to offset the cost of covering people with catastrophic long-term ailments.
You also must consider what Trump said not only before he ran for president but during the campaign, even while he was promising to fulfill Republican hopes of repealing the Obama law, which had been the Republican blueprint for universal coverage.
In his first dalliances with running for president in the 1990s and before he announced in 2015, he had one overriding objective, which was to see to it that every American had medical coverage. Nothing, he said, was more American than to guarantee medical care for everyone, no matter his or her incomes. He admired Medicare and Social Security, which was universal retirement insurance for the aged and infirm, and it seemed those were his blueprints for universal coverage. He disagreed with the House Republican budget plans to turn Medicare into a voucher program and Social Security into a private investment plan.
Does it make sense that a man with those beliefs would sign into law a bill that cancels the insurance for 22 million low-income Americans (some 400,000 in Arkansas alone) and substitutes no remedy? That is what a strong contingent of Republicans in Congress, whether Arkansas’ contingent it is not clear, want to happen, but we don’t think that is what Trump wants his legacy to be. Remember in one debate he said he would not allow anyone to die in the streets when he was president because they could not afford health insurance.
The biggest feature of Obamacare, at least for Arkansas, is government-paid insurance for families under 138 percent of the poverty line through the old Medicaid program. Arkansas developed its own formula for doing it by combining the Medicaid mandate with the other big Obamacare feature, a marketplace of private insurance plans available to everyone and with some government premium support if family incomes were below 400 percent of poverty. It has insured more than 300,000 of Arkansas’s poorest—almost all of them except undocumented immigrants.
Obamacare will be formally repealed—that much is certain because every Republican wants to remove universal health insurance from Obama’s legacy—but it is equally clear that most of Congress and the new president know that something must replace it and it must not appear to be less effective than Obamacare in insuring the country’s neediest.
House Republicans have touted a plan to convert all of Medicaid into block grants for the states—maybe as much total money as the government is spending now—and let the states decide how to spend it among their poor and impose any kind of requirements on poor people who accepted it. It would appear to be Obamacare without the name or the stiff rules states had to follow. But actually it would be a mammoth new burden to states like Arkansas. It would leave the Arkansas legislature and governor gasping at budget time to avoid raising taxes or cutting Medicaid benefits, education or other social programs dramatically. In 2019, probably the first year under the brave new post-Obamacare world, the federal government would be paying 93 percent of the cost of serving the poor under Obamacare but much less under a block-grant system. Arkansas presumably would start paying some 30 percent of expanded Medicaid costs, not the 7 percent under Obamacare.
Where will Gov. Hutchinson find the money for that and for the suddenly huge needs of the state medical institutions and struggling community hospitals like North Metro Medical Center? Stay tuned.
You should know that the one part of Obamacare that is certain to be repealed and not replaced are the higher taxes on the nation’s wealthy to pay for Medicare and the taxes on medical equipment makers and pharmaceutical companies, which are the real reasons Republicans and industry have demanded the repeal of Obamacare. The one certainty is that the repeal of Obamacare, whatever form it takes, will swell the nation’s budget deficits. But in the words of Dick Cheney, “deficits don’t matter.” —Ernie Dumas
