Single Issue Edition
Well friends, they did it. They passed an explicitly cruel and fiscally disastrous bill to strip health insurance from millions of Americans who have come to rely on it. Glory in your rage. Read this and revel in your disgust. And then figure out what we’re going to do next. I have some ideas below. Bottom line: I am FIRED UP and pissed off and hope you’ll join me in fighting back.
FIRST, WHAT THE BILL DOES: The American Health Care Act (ACHA) passed the House today by a vote of 217-213, with only 20 Republicans voting against it and no Democrats voting for it. It is in most ways identical to the ACHA that had to be yanked from the floor a month ago, when both “moderates” and hard-liners refused to support it. The only changes had made the bill crueler and less protective of the most vulnerable. (Here’s a quick rundown by Atul Gawande.) So here is what the bill does, based largely on the CBO’s analysis of the first bill, which remains operative with a few tweaks around the edges in the new bill:
- Yanks health insurance away from 24 million people, as the CBO projected of the first bill.
- Slashes Medicaid spending by almost $900 billion over the next decade, and directs nearly all of those funds into a massive tax cut for the richest 2% of Americans. The CBO analysis of the first bill -- whose provisions on this point are unchanged in the bill that passed -- estimated that 14 million Americans currently covered by Medicaid (by definition, poor or disabled) would lose their coverage.
- Turns Medicaid from a state matching subsidy to a capped per capita grant to states. This incentivizes states to kick off the most expensive insurees (the elderly and the disabled) from Medicaid so that federal dollars go farther.
- Allows states to opt to take Medicaid as a full block grant, which means the feds’ spending is strictly capped no matter the circumstances, but which gives states the freedom to kick anyone off the rolls they choose.
- Removes the progressive subsidies offered by Obamacare and replaces them with age-based (rather than income-based) flat tax credits.
- Allows insurers to charge dramatically higher premiums to older people.
- Allows states to get a waiver from Obamacare’s mandate to cover 10 essential health benefits, like pregnancy and hospitalizations, meaning that insurers could sell junk insurance.
- This provision also allows a single state to create rules that could apply nationwide that would allow employer-based insurers to impose annual and lifetime caps on coverage. Four steps: First, Obamacare banned the imposition of annual and lifetime caps, but only on coverage for essential health benefits. Second, Obamacare allowed large employers to pick from any state’s required coverage list -- permission that was “mostly meaningless because the ACA established a national set of essential benefits.” Third, a state obtains a waiver to the essential health benefits. Fourth, the employer picks the benefits of that state to set its coverage -- and voila, every employee’s plans “could once again impose coverage limits on anything from emergency services to inpatient care to prescription drugs.”
- “Similarly, plans would also no longer have to cap consumers’ out-of-pocket costs, since that ACA requirement also applies only to out-of-pocket costs for Essential Health Benefits.”
- Allows states to obtain a waiver to the rule barring discrimination on the basis of health status/preexisting conditions.
- This also means that the glory days of “medical underwriting” -- in which you have to give your entire medical history every time you try to sign up for insurance -- is back.
- “Shunts those with preexisting conditions into high-risk pools, which are absolutely the worst way to cover those patients; experience with them on the state level proves that they wind up underfunded, charge enormous premiums, provide inadequate benefits and can’t cover the population they’re meant for.”
THE AMENDMENTS MADE THE ORIGINAL BILL FAR WORSE: There were two main amendments to the AHCA that gave cover to the hard-liners and the “moderates” and allowed this vote to pass.
Hardliners Make Bill Crueler: The first, for the hardliners, was the McArthur Amendment. This was the change that allows states to seek waivers to the “community rating” rules (requiring insurers to charge the same rates regardless of preexisting conditions) and to the essential health benefits (mandating a list of essential benefits that all plans must cover, including maternity care, hospitalizations, mental health treatment, and substance abuse treatment). The process for getting those waivers is particularly terrifying (something I had not seen covered before doing research for this newsletter tonight): “States would receive automatic approval for waivers within 60 days as long as they attested that the waiver would lower premiums, increase coverage levels, stabilize the market, stabilize premiums for people with pre-existing conditions, or increase the choice of health plans in the state. There would be no federal review to determine whether such a waiver would actually achieve any of those goals.”
Moderates Hide Behind a Fig Leaf: After declaring himself a “No” vote on Monday, Fred Upton reversed course and presented a smoke and mirrors amendment that satisfied him (and a bunch of other “moderates”) to come on board just three days later. The Upton amendment purports to add $8 billion to help fund the “high risk pools” that states must create if they opt out of the other Obamacare provisions. The amendment doesn’t specify how the money has to be spent; “[s]tates could use the money to pay insurers directly to keep costs down, to help people buy insurance in the high-risk pool, or to provide direct subsidies for people to buy their own insurance.” This is a pathetic, paltry sum of money that goes nowhere close to actually providing coverage for people with preexisting conditions who may be shut out of the market entirely. “Assuming moderately generous premium subsidies of $21,000 per year for high-cost coverage, the Upton amendment could help cover 76,000 enrollees—a tiny fraction of the 130 million Americans with pre-existing conditions.” And as Sarah Kliff reminds us, we already know that high-risk pools are terrible. “There were 35 state high-risk pools before the Affordable Care Act passed. To control costs, they would often do things like charge higher premiums than the individual market. Most had waiting periods before they would pay claims on members’ preexisting conditions, meaning a cancer patient would need to pay premiums for six months or a year before the high-risk pool would cover her chemotherapy treatments.”
OKAY, SO WHAT CAN WE DO: First, we must breath. Second, we must rage and scream. Third, we should read some of the best summaries of exactly how cruel and shameful and disgusting and cruel this bill is. Fourth, we must NOT be complacent on the Senate to fix this disaster and shove this bill into the dark, dank hole in which it belongs. Fifth, we need to come at the House GOP -- yes, the House -- with everything we have. Ben Wickler of MoveOn made this point really well on Twitter this morning: “It will be tempting for activists to immediately swing their focus over to pressuring the Senate. Don't do it. Job one is BLOWBACK. Most of all, swing Senators will be watching to see what kind of political price GOP reps pay for voting to uninsure their constituents.” So if your congressman voted for the bill, FLOOD his/her office with calls and tell them that you will be working your hardest to defeat them in 2018. Another idea: Donate to Swing Left’s fund specifically for the eventual Democratic challengers to all 13 of the GOP members who voted for the bill and whose districts Clinton won. Swing Left is a genius organization that is targeting vulnerable GOP districts to flood them with activists, volunteers, and donors. The district funds are set up now so that the second there is a Democratic nominee, that person will have access to funds to hit the ground running against the GOP incumbent, rather than having to spend time fundraising while the incumbent sails through. Read more about their strategy here; I think their approach is genius. (I donated today to the general AHCA fund and specifically to the fund targeting Darrel Issa’s seat.) Most importantly, STAY ENGAGED. Activism is working. For example, Colorado’s Mike Coffman supported the first version of the AHCA. He faced unbelievable blowback from his constituents (and a very persuasive call from Yours Truly yesterday and this morning, on behalf of my grandmother who lives in his district), and today he voted AGAINST the bill. (I then called to thank him -- another important step for activists to remember!) The CBO score of the new AHCA will come out next week (yes, a week after the House voted), and it will be ugly. FORCE YOUR REPS AND YOUR SENATORS TO THINK ABOUT THOSE STATS, AND THE LIVES BEHIND THOSE STATS, EVERY TIME THEY CLOSE THEIR EYES.
MUST WATCH VIDEO OF THE WEEK: You’ve probably heard that Jimmy Kimmel may ultimately be credited with defeating the AHCA. That’s because of an incredibly moving monologue he delivered about the birth of his son last week and some serious medical issues that his son suffers from. It’s long, 10 minutes, but it’s really really worth watching to the end.
ENDORSEMENTS: A new feature where I endorse things I like.
- Swing Left
- “A federal court on Thursday ordered Georgia officials to extend the voter registration deadline through at least May 21 to be eligible to vote in the special election runoff in Georgia's sixth congressional district between Republican Karen Handel and Democrat Jon Ossoff.” (You can and should still give to Ossoff here. Handel is embracing Trump.)
- Jim Johnson. Are you a resident of NEW JERSEY? If so, the Democratic primary for governor is fast approaching, and I would urge you to support Jim Johnson. These two short ads provide a little background about him. I had the pleasure of meeting him a couple of weeks ago and he strikes me as the real deal. He's running as a good-government progressive against a do-nothing, Goldman Sachs Democrat. (Best evidence of his good judgment: He married Nancy Northrup, head of the Center for Reproductive Rights, the group that brought us the landmark SCOTUS victory in Whole Women's Health.) He is running a great race but needs money to get on the air in the last few weeks before the primary. Please send a little money his way if you can -- every little bit helps!
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