Senate Republicans are pushing hard for a vote this week on their plan to repeal and replace Obamacare, aka the ACA. But the Senate plan takes coverage away from 22 million Americans, according to a report from the Congressional Budget Office released on Monday. The CBO also projects the plan will reduce the deficit by $321 billion over the next decade. And the bill's authors utilized some trickery to get their bill scored slightly better than its House counterpart proposal, which President Donald Trump called "mean."
The Senate GOP proposal will phase out Medicaid's expansion, it will cap Medicaid spending to the states, it will repeal Obamacare taxes used to fund the program, and it will restructure subsidies to insurance customers. The federal government currently picks up between 50 and 100 percent of the states' healthcare costs. The Republicans want to reduce these costs through block grants that are capped to slow growth. This will leave it to the states to cover any difference and administer healthcare. But the effect will be to reduce federal Medicaid spending over time, leaving millions of those who need support most without health insurance.
In January President Donald Trump told The Washington Post, "We are going to have insurance for everybody. There was a philosophy in some circles that if you can't pay for it, you don't get it. That's not going to happen with us." The House GOP earlier had passed their version of health care, which President Trump feted at a White House ceremony with Congressional Republicans. But later he turned on them by describing the bill as "mean." Now he is pushing for passage of the Senate Republican bill, which is not dissimilar to the House version.
Health care represents one sixth of the U.S. gross domestic product, or more than $2.6 trillion. Medicaid spending has reached $575 billion annually. The Health Insurance Association of America defines Medicaid as a "government insurance program for persons of all ages whose income and resources are insufficient to pay for health care." Republicans have long strived to cut Medicaid costs in an effort to reduce the U.S. deficit. They believe that block granting it to the states will make it more efficient.
The federal government's options for reducing Medicaid costs are limited. It can reduce the number of people covered, it can reduce the benefit coverage, it can pay less for benefits, it can get doctors and hospitals to accept less in reimbursement, or it can ask beneficiaries to pay more. Both the House and Senate bills would have a devastating impact millions of Americans by throwing the problem to the states and cutting the growth of Medicaid subsidies over time through a cap on spending. While the CBO shows that healthcare price increases will in a couple years be less under the Senate version than Obamacare, those covered will get less for their money.
For more than seven years Republicans have railed against Obamacare. President Trump campaigned heavily against Obamacare, pledging at a Florida rally in October to repeal and replace it. "That begins with immediately repealing and replacing the disaster known as Obamacare," he promised. "You're going to have such great health care, at a tiny fraction of the cost--and it's going to be so easy." Four months later a frustrated President Trump told reporters, "It's an unbelievably complex subject. Nobody knew health care could be so complicated."
Senate Republican leadership turned this complicated task over to thirteen of its members, all men, who then crafted its health care bill behind closed doors. The measure was released to the public last Thursday, leaving little time for public scrutiny. The Affordable Care Act, by contrast, was debated over months of hearings and Republicans added more than one hundred amendments to the legislation. Clearly Senate Leader Mitch McConnell knew his caucus's bill would be unpopular. But now President Trump is championing the Senate bill, even though it will adversely impact millions of his own supporters while giving tax breaks to the rich, like the Trump family. All Trump, a self-proclaimed dealmaker, cares about is making a deal.
Ultimately, someone has to pay if health care is to cover those who can least afford it. The American Medical Association sent a letter to Leader McConnell warning that the Senate's Obamacare repeal plan could hurt America's "most vulnerable citizens." The key to covering more Americans while lowering health insurance costs is risk sharing, where the healthy contribute to pay the costs. But Congressional Republicans are more focused on fulfilling their campaign promise to repeal Obamacare, even at the risk of losing Congressional seats in the 2018 Midterm elections, especially in those states that have already accepted Medicaid coverage.
Yet President Trump is exhorting Republicans on Twitter--driving them to close the deal and perhaps off the cliff in 2018. "Republican Senators are working very hard to get there, with no help from the Democrats. Not easy! Perhaps just let OCare crash & burn!" he tweeted Monday. Of course it would be easier to fix Obamacare, and former House Speaker John Boehner warned Republicans that once you give people and entitlement you can't take it away.
So Republicans have replaced a "mean" proposal with a less mean proposal. Now passage rests in the hands of a handful of uncommitted Senate Republicans. Were Hippocrates, the father of medicine in Western Culture, alive today he would give each of them this advice: "Do no harm."
But this is politics, and nobody knew it could be so complicated.