If President Donald Trump thought the House's health care bill was "mean," what's the right word for the Senate version? Brutal? Heartless? Cynical? The bill Senate Majority Leader Mitch McConnell wrote in secret and wants to vote through his chamber within the week is in virtually every respect a worse piece of legislation than the House bill, a Congressional Budget Office analysis confirms. If it became law, millions of Americans would wind up with health insurance that costs more and covers less. The nation's health insurance exchanges would go from troubled to decimated. Sick people would actually find themselves locked out of the health insurance market, and those that have coverage would again face the risk of bankruptcy after they hit annual and lifetime caps. Unless Mr. McConnell's true goal was to convince Republicans that the Affordable Care Act was actually a pretty good idea, we can't fathom what he's trying to accomplish.
The big headline from the CBO's analysis of the bill was that it would result in 22 million fewer people with health insurance at the end of a decade, about the same as its estimate for the House bill. But there's a lot more in the fine print.
The Senate's legislation would reduce the deficit over 10 years by $321 billion, more than the House bill does, while also spending more to delay the end to the Medicaid expansion under the ACA. It accomplishes that by gouging even deeper into Medicaid in the later years — cutting $772 billion from projected spending during that time — and slashing the subsidies the government pays to help low-income consumers purchase health insurance. That $408 million cut means, for example, that net premiums would more than double for a 40-year-old who buys the cheapest plan and earns $26,500. A 64-year-old who earns $56,800 a year would see premiums for either a bronze or silver plan more than triple. Yet in all cases, the percentage of medical costs the plans cover would decline, meaning that not only are the premiums more expensive but out-of-pocket costs for co-pays, deductibles and co-insurance would go up, too.
(Some extremely low income individuals do fare better under the Senate bill than under Obamacare because the ACA was designed on the assumption that all states would expand Medicaid. The very poor in non-expansion states might theoretically be able to afford coverage now, though the premiums would still take up a hefty percentage of their income. But any benefit there is more than offset by the fact that the Senate bill is all but designed to force states to drop the Medicaid expansion and eventually cut back on even pre-ACA Medicaid coverage.)
All that might earn the bill the label "draconian," or perhaps "feudal," in that the reductions in coverage are paired with tax cuts that benefit the affluent almost exclusively and the very rich in particular. The liberal Center on Budget and Policy Priorities crunched the numbers and found that the value of the Senate bill's tax cuts for the nation's 400 wealthiest individuals would more than equal the cost of maintaining the Medicaid expansion in Alaska, Arkansas, Nevada and West Virginia put together. But what makes it truly cruel is the extent to which it resurrects the worst features of pre-Obamacare health insurance.
Just about everyone agrees that excluding people from coverage based on pre-existing conditions is unconscionable. The trick is finding a way of preventing people from waiting to buy insurance until after they're sick — insurance only works if people pay in while they're healthy to cover the costs when they or others need care. The ACA adopted what was originally a Republican idea: a mandate that individuals purchase coverage. In exchange, people got three important protections: guarantees that insurers would issue coverage, that they would provide an essential set of benefits and that they would not be charged more than they would be if they were healthy.
But the individual mandate became anathema when President Barack Obama adopted it, so the Senate deals with the pre-existing condition conundrum by requiring insurers to impose a six-month waiting period before benefits kick in for anyone who has allowed his or her coverage to lapse. Get cancer? Call us in six months, if you still can. But when you do, don't expect your policy to actually cover the care you need because the Senate bill effectively allows states to opt out of the minimum benefits requirements at will. Even if an insurer continues to cover those benefits, the Senate bill exempts them from prohibitions on annual and lifetime coverage caps. It's a recipe for people to die in bankruptcy.
Senator McConnell today delayed a procedural vote on the measure, but he and President Trump are in an all-out lobbying effort to persuade at least 50 GOP senators to vote for this legislation. They are expected to offer all manner of amendments and inducements, but this is not a bill that can be fixed. It is, in Trump parlance, "Big League Mean." The Senate should drop it.