How Trump Opponents Should Be Framing the Health Care Debate

We need to move beyond CBO scores and frame other critical components of the ACA.


A week after the election, with Bernie Sanders standing silently behind him, new minority leader Senator Chuck Schumer spoke:

“We heard the American people loud and clear…They felt that the government wasn’t working for them. They felt that the economy was rigged against them in many places. And big government was too beholden to big money and special interests. We needed a much sharper, bolder, stronger economic message and we needed to let the American people understand what we all believe that the system is not working for them and we’re going to change it.”

So why are Democrats missing the opportunity to drive home the link between income inequality and the Affordable Care Act?

It’s really this simple. According to Forbes “per capita health expenditures in 1958 were $134.00. At an average wage of $1.98, it took 15 days to cover those costs. In 2012 per capita health expenditure were $8,953 and it took 58 days to cover those costs at an average wage of $19.60.”

Think about it another way:

  • From 1958 to 2012, wages grew 10-fold ($1.98 to 19.60).
  • From 1958 to 2012, health costs grew over 70-fold ($134 to $8,953).

If health costs had also grown tenfold, health costs would be a manageable $1,340, not $8,953.

The Affordable Care Act closes this income inequality gap.

So, repeat after me…

ACA is medicine, income inequality the disease.

It’s income inequality, stupid!

ACA is medicine, income inequality the disease.

Don’t eliminate the medicine; cure the disease.  

ACA is medicine, income inequality the disease.

A living wage includes affording health care.

ACA is medicine, income inequality the disease.

Because you can’t buy what you can’t afford.

Why is it important?

Because we can’t let Republican “free market” solutions dominate the economic conversation—and they do.

Because the answer isn’t cheap skinny plans that don’t cover what you need; the answer is a living wage so you can afford the coverage you need.

It’s called the Affordable Care Act for a reason.

What does Swampcare Team say? It’s always about the free market.

Ted Cruz labels plans that cover your needs, “Cadillac plans” with “all the bells and whistles,” as if mental health and substance abuse coverage are akin to the sports package available for your car. The free market will lower prices and increase competition, they say, even though health care costs have risen faster than inflation and wages for the 50 free-market years preceding Obamacare.

They point to health care savings accounts, and like to blame the victim when suggesting we are too cavalier in our use of doctors and need to pay more fees directly, to shape up.

Free the markets, make better choices, and everyone will be covered for less money.

What’s not to like?

What happens in real life?

In real life, the massive shift of income from rich to poor mirrors the Obamacare population.

From 1978 to 2015, the share of national income for the bottom 20% of the population dropped from 20% to 12%, and the share of the top 1% grew from 11% to 20%. In 2011, the bottom 20% made $24,600 a year, the next 20% averaged $45,300 and the next 20% $66,000.

The ACA in a nutshell is subsidizing the 60% of the population who are victims of this shift.

In real life, we live with the sin of full-time working poor.

To even say “working” and “poor” in the same sentence should be beyond the pale, but it isn’t.

The Kaiser Foundation suggests more than 10 million of the 70-plus million Americans on Medicaid are full-time working poor. And that figure does not include their children or other family members like grandparents who could be living with them.

Do the math: the current Medicaid expansion approved under the ACA for a single person is 100% to 138% of the poverty level, which nets out to $12,203 to 16,423 for an individual. That’s $235 to $316 a week.

C’mon! No one is covering health care costs on those wages alone, no less starting health savings accounts with all their extra money.

In real life, the massive shift to part-time work has made heath care tenuous for many Americans.  

As if a national minimum wage of $7.25, unchanged since 2009, wasn’t enough, the 30-hour FT minimum and 50 employee business requirements permit employers, who are supposed to be the backbone of health care in our country—to avoid providing care altogether.

In an excellent study on the working poor and Obamacare in December 2015, USA Today estimated 5 million workers nationwide are ineligible for health care because employers keep them under 30 hours a week, not qualifying as full-time workers. And with a 50-employee threshold for a business to be required to offer health care, fast-food companies leverage the franchise corporate structure so each restaurant is a small business below the 50-person threshold.

Essentially, a good portion of government health care is subsidizing workers in the service industry and the health care costs their employers don’t provide. A nickname for the ACA might be the Fast Food, Service and Retail Industry Health Care Supplement Act.

What should Dems say?

"It's still the economy, stupid."

It is interesting to note James Carville had three phrases—one was “Change vs. more of the same”  and one was, ironically, “Don’t forget health care.” But the one everyone remembers was the economic message.

My hunch is Russia is more Iran-contra than Watergate, and we may have Trump around for a while. And if Republicans do pass their draconian repeal-and-replace bill, they will shift more onerous components affecting their base to after 2020. The next election will ultimately be determined by whether Trump delivers on good jobs. If he fails, the fickle independent voters will turn on him. So, it’s essential Democrats frame the health care fight through the prism of good jobs and income inequality.

The question isn’t just how are we going to pay for 70-plus million folks on Medicaid. The question is, why the hell are 70 million people in the richest country in the world on Medicaid? And why are 10 million people on Medicaid full-time working poor?  

Mathematically link income inequality to the ACA. I am not a statistician, but someone in the Democratic Party can calculate how many people would be off Medicaid if the minimum wage were $10, $12, $15? At $15, my guess would be 10 million-plus. Yes, some of those folks would shift into the tax subsidies portion of the ACA, but Medicaid rolls would drop.

Do some math, and make the links.

Swampcare is a job killer!

According to a study by George Washington University and the Commonwealth Fund, “By 2026, 924,000 jobs would be lost, gross state products would be $93 billion lower, and business output would be $148 billion less. About three-quarters of jobs lost (725,000) would be in the health care sector. States which expanded Medicaid would experience faster and deeper economic losses.”

Democrats need to be screaming from the rooftops that Swampcare is a job killer.

1 million jobs lost! 

Propose the Infrastructure Health Care Cost Reduction Amendment

Frame an infrastructure bill as a two-fer and calculate how many fewer folks would be on the rolls of the ACA or Medicaid if 2 million new, good-paying jobs with benefits were created by the US of A.

Consider the Level Playing Field Employer Amendment

Why are we subsidizing Walmart and McDonalds? Why should companies that do offer health care be at a disadvantage to companies making billions? Why not consider an amendment that simply requires all employer, full- and part-time, to pay at least some percentage of health care?

And if someone works less than 30 hours, the employer would still be responsible for some percentage of their care. (Yes, if someone worked 60 hours at multiple employers there would need to be a year-end give back.)

The Health Care Cost Freeze Amendment

Democrats need to get ahead of the curve on the cost issue, although costs are actually not skyrocketing as claimed. Actual health cost inflation in the last year of Obama was close to half of what it was in the last year of Bush. Free market pressures in a normal marketplace control costs. But health care is not a typical marketplace, and the free market hasn’t worked for 50 years, so Democrats need to take the lead.

Modify Trump's travel ban rationale, to freeze it while we figure it out, and apply it to health care. Let’s freeze all health care costs for 2 years and assemble a Health Care Cost Commission to recommend solutions.

The Bottom Line

Of course, I don’t expect Republicans to raise the minimum wage, require all employers to offer some health coverage or freeze costs, but Democrats need to be pressing the good jobs and income inequality issues relentlessly, every single day.

A country where one out of every five people is on Medicare? How did we get here? Income inequality is how we got here.

A society that once strove to offer every working man/woman an honest wage, with a pension and a gold watch, now has a permanent underclass of workers paid wages that simply don’t cover home ownership, college for their kids or basic healthcare coverage—without the ACA.

Logic would dictate you maintain the safety net while you raise wages and create good paying jobs. The Medicaid rolls and subsidies would then shrink. Instead, with greed in the drivers’ seat, and Christian ideals locked in the trunk, Republicans intend to solve the health care quandary with a cruel reverse logic: eliminate the subsidies and guilt those living on the edge with health savings accounts.

The ACA is the medicine, and the disease is income inequality.

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