But stinginess is still the essential problem for the Senate’s alternative. High-deductible insurance plans make less sense the poorer you get, which is why they should ideally be encouraged from the top of the income ladder down — through a cap on the tax subsidy for employer-provided insurance, ideally, a sound conservative idea left at the altar by this bill.
Pushing them from the bottom of society only makes sense if you’re also willing to pre-fund health savings accounts for the near-poor, so that they can actually hope to pay their out-of-pocket costs. But this costs money that Republicans prefer to reserve for tax cuts. So the bill’s attempted transition from Medicaid to private coverage would inevitably leave the people transitioning worse off, with deductibles that they couldn’t pay even if their choice of doctors were technically better.
Meanwhile the middle-class Americans most justifiably aggrieved by Obamacare — the people just above the subsidy cutoff, buying unsubsidized insurance that Obamacare made less affordable — will gain little from the bill, and because the subsidy ceiling is lowered (from 400 percent of poverty to 350 percent) their ranks will actually increase.
The House bill, flawed in so many respects, at least made an effort on this front, since its flat subsidy was available to the people currently getting hosed by Obamacare prices. But maintaining a smaller version of that subsidy would have, once again, cost money, so instead the health care law’s biggest losers will continue to lose out.
Politically, then, it’s very hard to see a clear constituency for this bill, apart from the mostly wealthy voters who will appreciate its rollback of Obamacare’s tax increases. Because it preserves more reasonable subsidies than the House bill and because its Medicaid drawdown happens in the distant 2020s — which is to say, perhaps never — it might not be an outright political catastrophe. But it’s still the act of a party dedicated primarily to rescuing the rich from their tax rates, rather than stewarding the common good.
The best conservative health policy analysis proceeds from the controversial but, I think, correct perspective that much health spending is wasted and that people do not value or benefit from insurance as much as liberal technocrats presume. That analysis lends support to some of the provisions in this bill. But a more holistic, less plutocratic…