The Senate’s Disastrous Health-Care Bill
How much of a surprise was the Better Care Reconciliation Act, the Senate’s super-secret health-care bill, which Mitch McConnell, the Majority Leader, finally revealed last Thursday? There had been intimations, from President Trump, among others, that it would fix some of the destructiveness of the House bill, which the Congressional Budget Office estimated would cause twenty-three million Americans to lose their insurance coverage. But it turns out that the Senate bill is just as miserable. The new C.B.O. estimate isn’t expected until next week, but there are indications that it won’t be good: the cuts to Medicaid, for example, may be even more severe than those in the House bill, which the C.B.O. calculated would amount to more than eight hundred billion dollars over the next ten years.
The Senate bill jettisons standards for care so thoroughly that, under its terms, it isn’t clear what it would even mean to be covered. Before Obamacare, when people who had insurance developed a serious health condition, they often discovered that it wasn’t covered by their policy, or that there were so many co-payments, deductibles, mysterious charges, and caps—including lifetime caps—that their coverage amounted to little more than a discount coupon on something that remained unaffordable. People found themselves without coverage for hospitalization, prescription drugs, and pediatric and chronic-disease care. A key contribution of the Affordable Care Act was to define each of those services, and some others, as “essential health benefits”—services that a plan had to cover in order to call itself a plan.
The House and the Senate bills both allow the states to waive the essential-benefit requirements. House Republicans justified this provision by expressing outrage at the inclusion of prenatal care in the benefits: Why, they asked, should men, who can’t get pregnant, have to pay for that? Such attempts to frame access to coverage as someone else’s problem are muddled as a matter of both practice and principle.
In America, the category of the vulnerable is a broad one. Medicaid, for example, covers seventy-four million low-income Americans—a fifth of the population. There is no simple picture of this group; according to the Kaiser Family Foundation, thirty-four million are children, eleven million are disabled, and seven million are elderly, a large number of whom live in nursing facilities. Many of those people led middle-class or even affluent lives, until their savings were consumed by the cost of residential care, which, in large part, is not covered by Medicare; nearly two-thirds of nursing-home patients are, at some point, on Medicaid.
One of Obamacare’s innovations was to expand Medicaid eligibility to include people slightly above the poverty level. The federal government now pays the states a percentage of what it costs them to care for eligible residents: if a state spends more, it gets more, within certain parameters. Both Republican plans would radically restructure the program, giving states limited sums. The states would then have to use their own money to make up for the shortfall—or they could choose to spend even less. This change would place particularly devastating financial pressures on the elderly, at a time when the population is aging.
Both plans would also strand many people afflicted by the opioid epidemic, a crisis that Trump and other Republicans have promised to address. In a letter to Senate leaders, protesting the Senate plan, major insurers noted that Medicaid pays for forty-one per cent of opioid-addiction treatment in the five states most affected. Meanwhile, many middle-class families rely on the A.C.A.’s essential health benefits, which include substance-abuse treatment, to deal with dependency issues. Now they will be more at risk of the financial collapse that addiction can bring, or perhaps have to watch loved ones drift away or die.
The Republican plans will be catastrophic for Americans in all states—including the tens of millions who live in states represented by Republicans. McConnell, Speaker of the House Paul Ryan, and others have brushed off concerns from constituents who say that Obamacare has saved their lives by claiming that the program has already “collapsed.” This is not true; the exchanges are under pressure, largely because of the uncertainties that the Republicans have introduced, but the percentage of Americans who are uninsured has fallen from sixteen per cent to nine per cent. The rate of personal bankruptcy, often attributable to medical costs, has also fallen.
Both Republican plans claim to protect people who have preëxisting conditions, another of the major advances of Obamacare. In the case of the House bill, that claim is plainly false: it does call for insurance companies to offer such plans, but it also allows them to make those plans prohibitively expensive, via state waivers. The Senate bill, in turn, professes to include price protection, but it presents insurers with other loopholes. And there are hints that even those protections might be traded away if McConnell needs to placate senators on the right in order to get the bill passed by next week, which is his goal. (The plan is to force it through with a simple majority, by the process known as reconciliation.)
There are fifty-two Republicans in the Senate, so McConnell can afford to lose the support of only two. Within hours of the plan’s release, however, four senators—Ted Cruz, Rand Paul, Mike Lee, and Ron Johnson—said that it was not conservative enough. This faction may take some comfort from the nearly one trillion dollars in tax cuts that come with the bill, most of them benefitting wealthier Americans. On Friday, Dean Heller, of Nevada, a state that Hillary Clinton won last year, signalled that he, too, would not support the bill as it stands, and other moderates may also defect.
McConnell hasn’t even pretended to include the Democrats in the process, and much of the criticism of the Senate bill, like much of the criticism of the Trump Presidency, has centered on the idea that norms are being violated, and standards abandoned. But, though the plans are morally shocking, politically they are not. After all, nineteen Republican state legislatures or governors refused to participate in the Medicaid expansion. And even some of the senators who complained most loudly about the process, John McCain among them, are expected to vote for the bill. That pattern, of expressed dismay followed by opportunistic accession, was on display in the Party’s surrender to Trump during the Presidential campaign. But the gutting of health care isn’t something that congressional Republicans can pin on Trump. It’s all on them, and they are the ones who will have to answer for it. ♦
