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    Democratic presidential candidates have spent years building a new vision of American policy, one where a lot more of us get our health insurance from the government.

    I see President Trump’s newly released budget as his counterproposal to all that. It envisions a really different future, one where government-run health care shrinks — and public programs become more difficult to sign up for.

    Here are some key health policy features of the Trump budget (you can read the full thing here):

    • Repealing Obamacare and replacing it with Graham-Cassidy. Those who followed the Obamacare repeal debate closely will certainly remember the replacement proposal from Sens. Lindsey Graham (R-SC) and Bill Cassidy (R-LA). As I’ve written previously, this plan would allow insurers to discriminate against those with preexisting conditions and significantly cut insurance subsidies for low- and middle-income Americans.
    • Cutting $845 billion from Medicare. These are some pretty significant cuts that are already getting a lot of attention. To be honest, I don’t see them as the most notable part of this budget. As Axios’s Sam Baker points out, a big chunk of these Medicare cuts are ones that have bipartisan backing — so much so that they the Obama administration proposed them in years past. Even Obamacare cut Medicare by $716 billion — something Republicans continually brought up in the 2012 election. At the same time, there are certain changes in the budget that could have a negative impact for patients: for example, the budget proposes requiring prior authorization for certain medical procedures that are likely to be the subject of fraud — which could make it harder for seniors to get care.
    • A nationwide work requirement for Medicaid. Republican governors in places like Arkansas and Wisconsin have recently begun requiring their Medicaid enrollees to work, go to school, or be job-searching in order to qualify for health benefits. The idea is to use the medical coverage as an incentive to get more Americans to join the workforce — but early data (primarily from Arkansas) suggests that these types of work requirements can be difficult to comply with, and people who really rely on their Medicaid plans are starting to lose coverage. The Trump budget would create a nationwide Medicaid work requirement that would save the government an estimated $245 billion — cuts that would likely come from fewer Americans getting coverage through the program.
    • Bigger copayments in Medicaid too. The Trump budget proposes “additional flexibility around benefits and cost-sharing, such as increasing copayments for non-emergency use of the emergency department.” We know from a lengthy body of health policy research that when you have higher costs associated with health care, patients cut back on their doctor trips — both the ones are needed and those that aren’t quite so necessary. You’d expect that a change like this might cut back on some unnecessary ER visits, but it’s also going to deter patients from seeking emergency care in cases where they really need it.
    • No more premium-free Obamacare plans. In many parts of the country, low-income Americans qualify for “zero premium” insurance plans: health coverage where the entire premium would be covered by their government tax credit. The Trump administration wants to put an end to that. In order to “increase consumer engagement,” the White House proposes that “all subsidized individuals that purchase health coverage on the Federal Exchange to contribute something to their healthcare coverage.” How exactly this would happen is not made clear in the budget proposal.

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    Higher copayments, work requirements, no more zero-premium Obamacare plans — take it all together and you create a health care system where it’s significantly harder and more expensive to go to the doctor.

    There are some benefits to this type of health care system, no doubt. When fewer people get public coverage — and those remaining people go to the doctor less because their copays are higher — then the government spends less money on health care. So if your biggest goal is reducing the deficit, this plan would check that box.

    But those spending cuts come with some undeniable human consequences. Bryce Covert recently wrote a compelling piece for the Nation, exploring the human consequences of Arkansas’s new Medicaid work requirement. One of the things she finds is that those who are having trouble keeping up with the bureaucracy of the work requirement — who are working but haven’t properly reported that to the state — are struggling to hold on to their coverage.

    What we’re seeing right now is two really different visions of the future of American health care. We have one from the Democrats that envisions a robust health care system, one without any copayments or deductibles. There are still holes in that vision — namely, how to pay for such a generous version of American health care — and I’d guess these proposals get revised to include some type of cost sharing as they work their way through Congress. All that being said, what Democrats are offering right now is a clear vision of how they think medical care should be in the United States: easily affordable and accessible to all Americans.

    The other vision offered by the Trump administration lays out a future in which the government spends less on health care — and, as a result, vulnerable populations get less medical care.

    This vision does not come with the difficult “how do you pay for it” questions that plague any Medicare-for-all proposal. But it comes with its own big question: namely, how are low-income Americans going to get by in a country where they get a lot less help affording basic medical services?

    The answer to that question is probably that they don’t get by very well. The future the Trump budget lays out is one in which richer Americans can do just fine buying their own health care. There aren’t big changes for those who get insurance at work, as higher-income Americans typically do. But it’s a future where, if you’re poor, seeking care gets a lot harder.

    This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inboxalong with more health care stats and news.

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