Health Care 'Access' is Not the Same as 'Coverage'

Watching top Republicans explain their proposed Affordable Care Act replacement can make you wonder who hijacked the English language.

For example, if you're like me, you might have been shocked by the news that 24 million fewer Americans will have health insurance by 2026 if the Republican-proposed alternative passes, according to the nonpartisan Congressional Budget Office -- including 14 million fewer people in the next year alone.

But that's OK, say Republican congressional leaders. House Speaker Paul Ryan, a Wisconsin Republican, already had declared such gloomy outlooks to be a "bogus" metric. It's not "coverage" that counts, he said; it's "access."

"What matters is that we're the lowering costs of health care and giving people access to affordable health care plans," Ryan said in a news conference. Ryan, a self-described "policy wonk," was excited.

He loves the mere sound of words like "freedom," "choice" and "access" even when the reality of "access" amounts to having the freedom to be offered decent health insurance but also being too poor to buy it.

And he's not alone. "Insurance is not really the end goal here," Office of Budget and Management Director Mick Mulvaney later told NBC. "We're choosing instead to look at what we think is more important to ordinary people: Can they afford to go to the doctor?"

OK, call me old-fashioned but I thought being able to afford to go to the doctor is why we have insurance.

But, no, said White House Chief Economic Adviser Gary Cohn to host Chris Wallace on Fox News Sunday about the prospect of millions losing their health insurance: "it's not just about coverage, it's about access to care. It's about access to be able to see your doctors."

So where did I get the idea that the goal was coverage? Maybe President Donald Trump had something to do with that when he promised a Republican plan that would provide "insurance for everybody."

But he also said in a White House meeting with House Republicans after the Grand Old Party's proposed legislation was unveiled, that it "will lower costs, expand choices, increase competition and ensure health care access for all Americans."

There's that word "access" again. By now, I suppose, we should know from experience that only the president's most recent version of the truth should be believed, if that.

What gives? Is promising "access" a nice-sounding squishy doublespeak way to say, "We're not giving you any more money to help you buy insurance?"

That's the biggest reason why the CBO and other analysts expect to see millions lose coverage under the Republican plan. Yet Speaker Ryan and other GOP leaders are more excited by the $337 billion that the CBO says the federal government will save over the next decade by shifting most of the ACA's health care burden back to the states and to individuals.

The Republican plan would remove mandates that require everyone to buy insurance, which enables the ACA to bar insurance companies from denying coverage because of preexisting conditions. It would replace subsidies with tax credits to help low-income people buy insurance and expand health savings accounts so more people could save more of their own money to pay for their own health care.

But market-driven incentives work best for people who can afford them. I like HSAs, for example, but households that are living paycheck-to-paycheck often find they simply can't afford to salt away much savings. One health crisis can eat up your health savings overnight. And there goes your "access."

All of which makes it all the more poignant -- or sad, as President Trump might tweet -- that the biggest losers in what's being called "Trumpcare" probably would be the core supporters of President Trump's election campaign.

The same lower-income, older voters who voted for him in rural red-state America stand to lose more in federal insurance subsidies than any other demographic, according to an analysis of country voting and tax credit data by Noam Levey of the Los Angeles Times.

That's the political base that Trump in his inaugural address lauded as the forgotten men and women to whom he had given a political voice. Now the burden is on Trump to show whether "access" to health insurance is as good as the real thing.

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(E-mail Clarence Page at cpage@chicagotribune.com.)