The American Health Care Act, Act 2

It’s time to raise your voice.

When the House of Representatives failed to pass the American Health Care Act in March, we thought they would move on to other things. They had already faced the wrath of their constituents in town halls across the country, defending themselves against charges that they were taking people’s health care away.

But a promise is a promise, and the Republicans had promised their voters they would get rid of Obamacare. So they began to negotiate — only instead of negotiating with the moderates in their party and perhaps some Democrats, they chose to work with the tea party faction, who now call themselves, without irony, the Freedom Caucus — which had disparaged the original AHCA as “Obamacare-lite.” If the angry constituents packing town halls to capacity thought the first iteration of the AHCA was too extreme, what on earth made House Republicans think a Freedom Caucus makeover would produce a bill that would inspire less animosity than the first?


We must insist that our representatives remember that health care is a matter of life and death.


So Tom MacArthur, a supposedly moderate Republican who makes Ronald Reagan look liberal, and Mark Meadows, the Freedom Caucus leader who makes Reagan look like a full-blown socialist, hammered out a deal. The tea party objection to the AHCA was that it didn’t get rid of the ACA’s regulations on insurance companies — such as barring insurers from charging more money to women, older patients, or patients with preexisting conditions, or requiring them to cover essential services like preventive health care without cost to patients, emergency services, prescription drugs, and prenatal care. MacArthur and Meadows’ supposed compromise allows states to apply for waivers to opt out of these essential services, or to allow higher rates for those with preexisting conditions if they set up “high-risk pools.” MacArthur’s constituents were not pleased.

A word about insurance and shared risk. When you buy a house, you buy homeowner’s insurance. It covers water damage, theft, fire, etc. Most people never use these policies, or use them only for relatively minor damage or loss. Therefore, when someone’s house does burn down, there is plenty of money in the pool to cover that emergency. This is why it made sense, if we were going with private insurance, to insist that younger and healthier people buy health insurance if we required insurance companies to cover more services and sicker people. (Whether private insurance belongs in health care at all is another subject altogether.)

High-risk pools take people with high medical expenses out of the general pool, which lowers costs for healthier people but is usually impossible for the sick to afford. According to CNN:

High-risk pools have long been a favorite tool of Republicans, but they have a very checkered past. They were typically severely underfunded, charged participants high premiums, excluded coverage of pre-existing conditions initially and had waiting lists for enrollment.

Some 35 states ran high risk pools prior to Obamacare. In 2011, states had to kick in $1.2 billion to cover 226,000 people enrolled in the programs.

Although the Congressional Budget Office has not scored the final version of the bill, a study was published just before the House voted on the bill, and it showed just how inadequate the proposed funding is. From CNBC:

The bill’s $23 billion in funding specifically for such people would cover just 110,000 Americans …  That’s only 5 percent of the 2.2 million current enrollees in the individual insurance market with some type of pre-existing chronic condition.

This still worried moderate Republicans who wanted more protections for those with preexisting conditions. So the White House met with Reps. Fred Upton and Billy Long, and they came up with an additional $8 billion over five years to help people in the high risk pools pay their high medical costs. The bill already allocated $23 billion over 10 years for these high-risk pools.

Another problem with the compromise bill ignored by the Republican moderates is allowing the states to cut the list of essential services. The ACA forbids insurers from setting annual or lifetime caps on what they will pay for a patient’s essential services. So if a state takes pregnancy, maternity, and postpartum care off their list of essential services, insurers based in that state can cap the amount of money they will pay for maternity care. If there are any complications surrounding pregnancy or childbirth, the patient is responsible for all costs above that cap. This applies to employer-provided insurance as well as insurance sold in the individual market. And we can assume most of the larger insurance companies will base themselves in the states with the fewest essential benefits, which will then apply in all states where they do business. (Millions of workers insured through their employers also could lose insurance because the bill eliminates the rule that businesses with 50 or more employees must provide insurance.)

How might allowing states to define “essential services” play out? For clues, look to the past: Medicaid expansion is already optional to the states, thanks to a Supreme Court decision that found the ACA constitutional, but said the law as written coerced states into expanding Medicaid by authorizing the government to withhold all Medicaid funding. Predictably, 19 states, including the poorest states that would have benefited most from the expansion, chose not to take money from the federal government to improve the heath and well-being of their citizens; ironically, they saw larger increases in their Medicaid costs than the states that accepted the expansion. (Some Republican governors saw the benefits the expansion would bring to their states. Arizona Gov. Jan Brewer, if you remember, threatened not to sign any bills until the Legislature passed Medicaid expansion, and actually vetoed a number of bills, showing how serious she was.)

But the House managed to herd enough cats to get a bill to the Senate that was worse than the original. The House bill is not about health care. It’s about getting the government out of health care and cutting taxes. But all money bills, as I learned in fifth grade social studies, must originate in the House, which was elected by the people, and not in the Senate, which originally was elected by state legislatures. Without a House bill the Senate could do nothing. So the Senate has said it will write its own bill, which is bound to be very different. There are actually Republican senators who want a health care bill, though if they really do, I don’t see why they don’t just fix what’s wrong with the ACA.

So what is the Senate doing? They have set up a working group, which unsurprisingly is made up entirely of 13 white men. Women like Sen. Susan Collins, who even wrote her own health care bill once before, can come to meetings if they want, but are not part of the core group. How did Mitch McConnell mansplain this?

“The working group that counts is all 52 of us,” McConnell told reporters, referring to all 52 Republican senators in the 100-member chamber. “Nobody is being excluded based upon gender … Everybody’s at the table. Everybody.”

To which Washington Sen. Patty Murray responded that she hoped they were not writing it in the men’s locker room.

On one side of the Republican political spectrum, Sens. Susan Collins of Maine and Lisa Murkowsky of Alaska have said they will not vote for any bill that defunds Planned Parenthood, and on the other side, the Senate has its own tea party fanatics to placate. Senate Republicans can only afford to lose three votes to pass anything, so crafting a bill that can please enough people could be difficult. But McConnell is determined to get something passed, so we must be vigilant.

So now we wait, but waiting does not have to be passive. We should contact our senators’ offices at each stage of the process to let them know what we think. Call Sens. Jeff Flake and John McCain, visit their local offices, protest, write letters, call for and attend town halls. Health care is a matter of life and death, and we must insist that our representatives in Congress remember this.

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