For weeks, Americans were left to wonder what 13 Republican senators were doing in their behind-closed-doors rewrite of the American Health Care Act. Now that they’ve released the bill, we’re left to wonder … what in the heck were they doing? This new bill is almost exactly the same as the old one and is likely to have the same devastating consequences for millions of Americans.
Here are the major differences: Rather than basing subsidies to help people buy health insurance on age, as the House bill did, the Senate version bases them on income, as Obamacare does. Older, relatively low-income consumers who were not yet eligible for Medicare fared particularly poorly under the House plan, so the change may benefit them but at the expense of younger, healthier individuals whose participation in the health insurance marketplace is crucial to its viability. That change, coupled with the elimination of the requirement that individuals have health insurance, could put an even greater strain on the health exchanges than the current GOP-manufactured uncertainty about Obamacare is producing.
The other big change is that the Affordable Health Care Act’s expansion of Medicaid to more low-income adults would be phased out more slowly than in the House plan. That may be important to some senators who worry about their next re-election campaigns, but it’s not much comfort to those who will be jettisoned from the roles at one time or another.
And that reprieve comes at a cost. Because the Senate must maintain the the House plan’s budget savings in order to employ procedural moves that strip Democrats of the ability to filibuster the bill, the added expense of a few more years of Medicaid expansion must be offset, and that means even greater long-term cuts to the program.
Like the House bill, the Senate would fundamentally re-write Medicaid. Since its inception, the program has been an open-ended system of cost sharing between the federal and state governments, but the House and Senate legislation would cap the amount the federal government would provide to each state, with the amount increasing at a rate that is not expected to keep up with costs. States would be left with the choice of either curtailing eligibility and benefits or raising taxes to maintain coverage.
The upshot is that changes to Medicaid won’t just hurt those who gained insurance under the Obamacare expansion but also the disabled and many nursing home residents — often middle income people who run through their savings and become eligible for Medicaid’s long-term care coverage.
Fundamentally, this bill is not about shoring up health insurance markets, expanding coverage, reducing health care costs or eliminating injustices like lifetime benefit caps and exclusions on those with pre-existing conditions. It’s not really a health care bill at all. It’s a tax cut for the affluent paid for by cutting health insurance benefits to the poor. The House bill was estimated to cut taxes by about $600 billion over 10 years, almost all of which was paid by individuals earning more than $200,000 a year and couples earning more than $250,000. The rest of the legislation, like an attempt to de-fund Planned Parenthood, is just window dressing.
The Congressional Budget Office is expected to release its estimates of the bill’s cost and its effects on the number of insured within a few days, but chances are it won’t materially alter the expectation that its tax cuts benefiting the top 5 percent (and mainly the top 1 percent) will come at the expense of tens of millions fewer people with health insurance in the coming decade.
The House version of the AHCA is profoundly unpopular. New polling from the University of Maryland’s Program for Public Consultation found that not only do two-thirds of voters nationally oppose the bill as a whole, majorities of Republicans in solidly Republican congressional districts oppose its key provisions. There’s no reason to expect the Senate version will be viewed any differently.
Senate Majority Leader Mitch McConnell remains determined to get a vote on this bill before the July 4 recess, evidently to ensure that members of his caucus can demonstrate that they fulfilled campaign pledges to repeal and replace Obamacare. But this is one promise they — and the American people — would be better off if they didn’t keep.
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