What’s in a Name: Repealing the Affordable Care Act

Supporters drop off petitions and rally at Rep. Martha McSally’s Tucson office, March 15, 2017

As this post goes to press, word has come that Speaker Paul Ryan has pulled the American Health Care Act, being unable to muster enough votes to pass it. So we have escaped that disaster, and it appears no attempt to repeal the Affordable Care Act will proceed in the near future. But the fight is not over. Aspects of this bill will come up in other forms and we will have to be vigilant. But this is a victory for activism, so many thanks to all of you who made phone calls, demonstrated, told your stories, and reminded the Republicans that destroying something is not the same as governing.

So as you read this, realize what we have escaped, and what we need to watch out for as we proceed.

People were going to die. But the free market would have triumphed.

Republicans called it Obamacare, and used that name as a slur to run against President Obama in 2012. It didn’t win that race for them, but there are enough people in this country for whom the name Obama is enough to damn a program. One woman, whose son lost his job and had his monthly insurance premium fall from $567 to $88, attributes that decrease to the tax credits in Trump and Ryan’s new American Health Care Act. You know, the bill that never passed. In actuality, her son became eligible for a subsidy under Obamacare — the Affordable Care Act — which is still the law.

Paul Ryan and his cronies in the House of Representatives hated the Affordable Care Act before it was written. They hated it even more when it passed and more than that when it was implemented.

What did they hate about it? They hated that the government was helping people. They don’t believe the government has any business helping people. Ever. They also hated that it added a tax on some rich people and businesses to help those who are less rich. And they hated, perhaps most of all, that it told insurance companies to do things that interfered with their profits. The first thing implemented in the law was the Patient’s Bill of Rights, which outlawed insurance practices like setting annual or lifetime limits on coverage for medical treatments. Like refusing to sell policies to people with pre-existing conditions. Like cutting off someone’s insurance when they got sick. It made annual examinations and recommended cancer screenings free of cost to the patient. It allowed parents to keep children on their insurance plans until they were 26.

The House kept trying to undo the ACA, but of course were unable to get a bill past the Senate or President Obama, but as soon as a Republican became president they rushed to get a bill through that could actually be signed into law.

Constituents at Rep. McSally’s town hall, Sahuarita, Arizona, February 23, 2017

But a funny thing happened on the way to the marketplace. At demonstrations, visits to legislators’ offices, and constituent town halls people began to tell their Republican lawmakers how the ACA had helped them, in many cases saving lives. Parents of young adults liked that they could keep their children on their policies longer. Parents of children with serious health problems liked that their children would not hit a lifetime cap on insurance payments, and would be able to get their own insurance as adults. Older people and disabled folks on Medicare liked that they could get their annual physical without any cost to them, and that the doughnut hole in Medicare drug coverage, which could cost them thousands of dollars every year, was no longer a problem. Women liked that they could get birth control without cost, and that they couldn’t be charged extra for being women. People with chronic diseases could actually get insurance to help cover their care and treatment. Working people in low-paying jobs without benefits liked Medicaid expansion in the 31 states that passed it.

Republican lawmakers had been so focused on the “Obama” in Obamacare that they had forgotten about the “care.” Now they had to realize that constituents who hadn’t been able to get insurance before were actually getting medical care because of the bill and didn’t want to lose it.

Lawmakers had to pretend to listen, while still going ahead with their original intent. So they added some window dressing. Young adults could still be on their parents’ policies until age 26. They paid lip service to people with pre-existing conditions, but even here there was a caveat. Insurers can’t refuse coverage to people with pre-existing conditions — but only if the person could prove they had 18 months of continuous coverage before.

Even that is too much for some of the drown-it-in-the-bathtub wing of the Republican party, who dubbed the bill “Obamacare Lite.” They are wrong, of course, as the AHCA would have ended the ACA taxes and included further tax breaks for middle- and upper-middle-class folks, and eliminated the consumer protections of the ACA, but as long as their stubbornness forced them to oppose the bill, perhaps I shouldn’t look a gift horse in the mouth.

So what would the new bill actually have done? The structure of the ACA would have been destroyed completely — the Patient’s Bill of Rights, the exchanges, the subsidies, the indexing of subsidies when costs rise, the help for insurance companies that suffered losses for participating (which had been blocked by Republicans anyway), the expansion of Medicaid. And all recognition of income inequality is gone. Totally. As is any way to pay for what’s left.

In order to avoid a filibuster in the Senate, House Republicans framed the bill as a tax bill, so it could reach the Senate in a reconciliation budget bill. And in many ways this bill was more about the budget and taxes than about health care. It would have eliminated the tax provisions of the ACA, including a tax increase for people earning more than $200,000 and businesses earning more than $250,000 with 50 or more employees, and subsidies for low- and moderate-income people. The new bill would have eliminated the increases and moved to a tax credit instead of a subsidy, which is rated by age, not by income. In addition, it would have raised the limits on health savings accounts, which are tax-exempt accounts to help with medical costs like deductibles and copays.

What it didn’t address was the provision of medical care, nor did it cut the cost of medical care. It merely shifted it from the federal government and insurance companies to state governments and the people.

But the Republicans managed to include a couple of provisions near and dear to their hearts. They completely restructured Medicaid, seriously cutting the federal contribution, thereby putting more burden on the states, which inevitably would have led to fewer people receiving the benefit, besides the people covered under Medicaid expansion. And, of course, what would a House health care bill be unless it defunded Planned Parenthood? What it actually would have done was bar Medicaid payments to Planned Parenthood for one year, with the intention to renew it annually.

This is only part of the impact the bill would have had on women’s health. The Patient’s Bill of Rights in the ACA forbids gender-rating of insurance. Women used to be charged more for insurance in the individual market because insurance companies claimed women’s health care cost them more — women were more likely to visit doctors, have babies, and live longer than men. This form of sex-based discrimination could have come back.

Additionally, under the ACA, prenatal, maternity, and postpartum care are included among the basic services insurance must cover. And with preventive care being covered without cost-sharing, women had more choice in their methods of contraception. This last provision, though, can and probably will be taken away by Tom Price — the list of covered preventive care is not set in the law and can be changed even now, even with the ACA remaining the law of the land.

The birth control provision has been fought by the right from the beginning. What is the problem with insurance providing free contraception? From an article about the Day Without a Woman in the conservative publication National Review:

In reality, the complementarity of the sexes is enormously beneficial to society, and to erase it would be a serious loss. A feminism that denies sex differences or that sees the sexes as in competition must necessarily be aided by an agenda of expansive birth control and abortion, both of which can function as attempts to make women more like men — able to engage in consequence-free sex.

I have never seen the opposition to birth control so clearly explained.

And since the American Health Care Act was hardest on the poor, the sick, the old, the mentally ill, and those in medically under-served communities, women who fall into these categories would have faced even greater hardships.

If this bill had passed, people were going to die. But the free market would have triumphed.

However, the Congressional Budget Office issued its report on the new bill on March 13. The report estimates that over 10 years, 24,000 Americans would have lost their insurance — 14,000 in the first year, mostly healthy young people who would no longer be mandated to buy policies.

Tom Price, questioning these numbers, says young people won’t give up having insurance because they’ll be able to buy the kind of plan they want.

Let’s parse that. Young people supposedly hate the ACA because it takes away their choice — they have to buy insurance or pay a fine. Instead of using this freedom to decline insurance, Price believes they could have found a policy that meets their needs. Then they would have a real choice. (Isn’t it interesting how much Republicans are using the word “choice” these days?)

What would that choice have looked like? They could have bought policies that were cheap but didn’t cover much. Policies that no longer had to cover the annual check-up that is all many young people need, with labs and cancer screenings, not to mention the young women who would no longer be able to get their birth control without cost-sharing. These are the insurance provisions most people between 26 and 30-something actually use. So they can pay for catastrophic coverage, I suppose, or they can pay for their own birth control and wellness care and skip the premium altogether, gambling that they won’t get cancer or be hit by a bus.

What a great choice they would have had.