I’m trying not to swear as much in public writing anymore as I like my communications director too much.
There’s been a lot of commentary on the left about how this bill allegedly erodes the safety net. It does no such thing. It replaces the Medicaid expansion under Obamacare with tax credits to buy individually purchased insurance.
His point is that people who make under 133% FPL can buy a 58% Actuarial Value (AV) plan for between 2.0% and 2.5% of income. Voila, it is the same.
Currently, people who make under 100%-138% FPL are either eligible for Cost Sharing Reduction Silver plans at 94% AV or qualify for Medicaid expansion. In Expansion states, people making under 100% of FPL qualify for Medicaid expansion at 98% to 100% AV. People in non-expansion states who earn under 100% FPL are better off as they currently get nothing and they could get something.
He is arguing that a 58% AV plan will be the same thing. A 58% AV plan has a $7,000 or more deductible in 2018. 94% CSR plans are $300 deductibles. Even being charitable and saying that the state stability and innovation funds can be used in place of CSR funding for these populations, the money is insufficient to bring the AV up to anything remotely close to what they are currently receiving through Medicaid or CSR Silvers.
Under the most favorable reading to Roy, he is advocating $2,000 or more individual deductibles for people currently on Medicaid expansion. We know from the Rand Health Insurance Experiment that there is a significant population who has worse health outcomes when their care is subject to light cost sharing (hint, $2,000 or 12% or more of single individual income is heavy cost sharing). And that population is people with low incomes**.
Importantly it did find that one population saw detrimental health outcomes as a result of paying more for health services- low-income folks
— Emma Sandoe (@emma_sandoe) June 25, 2017
So there is not just a difference in degree but in kind between Medicaid and Silver CSR cost sharing and his preferred cost sharing levels for people with low incomes. That difference is sufficient to say that Medicaid as we know it is destroyed in concept and execution under the Senate bill for the Expansion population.
** Ware JE Jr, Brook RH, Rogers WH, Keeler EB, Davies AR, Sherbourne CD, et al. Comparison of health outcomes at a health maintenance organisation with those of fee-for-service care. Lancet 1986;1(8488):1017-22.