It’s up to the U.S. Senate now whether tens of millions of Americans get stripped of the health insurance they obtained under the Affordable Care Act, aka Obamacare, or what kind of coverage they might have under some version of the American Health Care Act aka Trumpcare.
News organizations have posted some good, factual summaries of Trumpcare vs. Obamacare, as passed by the House last week, including here and here and here. The Congressional Budget Office, the federal outfit that is supposed to provide lawmakers a nonpartisan, independent analysis of the costs and effects of legislation, will score the House bill sometime this week so Americans really know what the bill does and how much it costs.
But analysts already note that this version of Trumpcare:
- Strips tens of millions of Americans, particularly those on Medicaid, of coverage.
- Halts the commitment, via Medicaid, to provide broad federal support to the poor, old, disabled, and chronically ill, converting funding for them, instead, to lesser, state block grants whose amounts would not be open but would be decided each fiscal year.
- Eliminates the individual mandate, the national requirement that Americans carry health insurance. This move had helped spread the risks and soaring costs of health care among the broadest populations.
- Turns over to states the decision by waiver whether to protect consumers from insurers charging them higher premiums, likely big sums, based on companies’ determinations whether they have pre-existing conditions.
- Undercuts key requirements for insurers to provide minimum essential health benefits, again giving states waiver powers to decide whether patients get coverages for hospitalization, emergency treatment, maternity care, and preventive services.
- Puts in jeopardy, again by allowing states to decide by waiver, whether insurers may cap coverage and benefits for long-running conditions, eliminating so-called lifetime limits clauses.
- Raises major questions, not just about coverage through Medicaid and federal exchanges, but more crucially about the giant source of health insurance for most Americans: employer-based programs.
After weeks of hearing constituents’ angry complaints about their ACA repeal-and-replacement plans, and after failing before to even bring a bill up for a vote, House Republicans shifted in a matter of hours to approving a revised version of Trumpcare. That happened when so-called “moderates” put stock in a plan that would add $8 billion more to “high risk” pools, supposedly to help more Americans with coverage when insurers shock them with sizable premiums to pay for their chronic illnesses and other pre-existing conditions. That may make it worth the time to read more about how such pools haven’t worked before, and how the GOP funding may be woefully inadequate to address potential needs under Trumpcare.
To be sure, the House version of Trumpcare may be a pyrrhic victory for the GOP. The measure has managed to create a rare unity in its infuriated opposition from doctors, hospitals, insurers, patient advocacy groups, and the AARP, one of the largest and most powerful interest organizations in the nation. Even party stalwarts like Sen. Lindsey Graham of South Carolina say they’re deeply troubled that House members voted on their latest iteration of the AHCA in such haste, especially without a CBO analysis. They reconsidered Trumpcare within days, after just weeks of discussion, and even as the measure was amended, supposedly in significant fashion. Many House members were candid in confessing that they really hadn’t read their own bill.
After seven years and more than five dozen attempts to repeal and replace Obamacare, was the House vote—with Democrats singing a “bye-bye” tune at opponents and Republicans racing to drink celebratory beers when their work was, maybe, half done—the best, most carefully thought through way to deal with a $3 trillion a year sector of the economy that comprises 17.5 percent of our GDP, not to mention the very lives of Americans (see comedian Jimmy Kimmel’s heartfelt monologue)?
Although many of us have decided that health care is a right for all Americans and not a privilege, GOP partisans have put forth some disturbing, deeply divisive views with Trumpcare, which has veered nearer to being rooted only in beliefs rather than evidence-based public policy, including notions that:
- The rich deserve not equal but much higher consideration than the rest of us. President Trump and GOP leaders have made clear that a driving concern for them in the AHCA isn’t Americans’ well-being but rather finding $1 trillion to provide tax cuts that mostly benefit those most well off. They achieve their aims largely by pulling more than $800 billion out of Medicaid.
- Sickness is a blame game, in which those who fall ill do so somehow due to their own actions or choices. “Good people don’t get sick.” This fault-finding also means that no matter how catastrophic circumstances become, you’re on your own. From House Speaker Paul Ryan down through the ranks, GOP representatives have denounced a fundamental of insurance—that risks and costs, to the benefit of the many, should be shared widely, though this may mean some pay more.
- The concerns of younger, healthier, and wealthier (see above) Americans take precedence over the needs of those who are older, sicker, and poorer. Not only would the House gut Medicaid to the detriment of the poor, disabled, and chronically ill—the program also significantly benefits the middle-class, as I’ve written—the House’s Trumpcare allows insurers to charge older Americans more than the young, five times as much.
I’ve written how troubling I find it that the GOP wants to let geography determine Americans’ lives, and this policy disposition only worsens with the idea of state waivers on critical issues like essential minimum health benefits and pre-existing conditions. Although some Pollyana advocates have said no state would put its residents health at risk by seeking waivers under the House version of Trumpcare, Gov. Scott Walker, a Republican in Wisconsin, already has expressed interest. What kind of nation will we be if this iteration of Trumpcare advances and Wisconsin would have one kind of health coverage, while Illinois or Michigan had vastly different types? What if Minnesota comes up with something grand—should Americans, as one GOP lawmaker has suggested, get up and move just for their health coverage?
I know the Obamacare-Trumpcare debate is painful, especially trying to keep up with complex health policy issues. But our health and wellbeing is at stake. In my practice, I see the major harms that patients suffer while seeking medical services. And it bothers me to see how many of us struggle with the giant hardships of trying to afford good medical care. Obamacare is imperfect. But casting tens of millions of Americans off coverage, jacking up the prices for health insurance for millions more, trusting profit-hungry free markets to do what’s best for us—these all are unconscionable. We need to keep an eagle eye on what happens in the Senate, and the leaders there would be well served to heed the powerful words of a young Massachusetts lawmaker on the topic of health care.