At last, Republican senators have unveiled their crafted-in-secret health bill, and everyone, including other Republican senators, are scrambling to understand the 142-page "Better Care Reconciliation Act of 2017."
To know whether it's truly "better care," and for which patients, if any, we still need the Congressional Budget Office to weigh in. But some California advocates say the “discussion draft” is clear enough to conclude that the bill would be “disproportionately devastating” for California’s health care system.
“If the House bill was mean, as the President termed it, the Senate bill was actually meaner and crueler,” said Anthony Wright, executive director of Health Access California. “It has harsher cuts, especially to the Medicaid program that covers 14 million Californians."
In the meantime, here are my five takeaways from the bill:
1. 'Repeal and Replace' Rhetoric Should Be … Repealed
At this point, it’s inaccurate and misleading. The Republican bill doesn’t repeal all of President Obama's health care law known as the Affordable Care Act, or Obamacare. Nor does it replace it with anything. The bill maintains the basic mechanics of the ACA but rolls back the financial assistance and some of the consumer protections. In addition, a huge part of this bill has nothing to do with Obamacare: It proposes a radical dismemberment of Medicaid as we know it.
Let’s describe what the bill actually does: It’s an Obamacare rollback and a Medicaid cutback.
2. Much Less Aid for Medicaid
The Senate bill will phase out one of the ACA’s most visible accomplishments: the expansion of Medicaid (Medi-Cal in California) to poor, uninsured adults. That means 3.7 million Californians who got Medi-Cal since 2014 will eventually lose it.
But there's more. The Senate plan will also cut funding for traditional Medi-Cal, and the cuts will be deeper, over time, than even the House Republicans proposed.
In California, Medi-Cal covers one-third of all residents, half of all children, and two-thirds of seniors in nursing homes.
Who pays for their care if the feds pay less? The short answer is no one -- or state taxpayers.
3. What About Covered California? Could It help?
Not really. The Senate version tries to assuage pre-Medicare seniors (below age 65) who were alarmed that the House bill would have given them only a maximum tax credit of $4,000 to buy a plan, no matter the plan’s price. The Senate bill reverts to the ACA mechanism of offering tax credits based on income, not age. But, insurers can still charge older people five times what they charge younger people.
And tax credits would only be offered to people with incomes below 350 percent of the federal poverty level, down from the ACA’s 400 percent. Do you make $42,000-$48,000 a year? You would no longer qualify for any subsidies on Covered California.
That’s not all. Other complicated changes to the exchanges mean premiums and deductibles would go up, and special ACA grants that help reduce those deductibles disappear.
4. Winners? Or Just Losers: Pre-existing conditions vs. Planned Parenthood
The Senate bill appears to drop a wildly unpopular provision that is still in the House bill -- the possibility that your state might allow insurers to refuse to cover people with pre-existing conditions, or charge them much more. That seems like good news for cancer survivors and millions of others with chronic illnesses. They can't be denied coverage, or charged more up front.
But experts who have read the bill closely say there are loopholes that would allow individual states to loosen regulations on insurers -- enabling those insurers to carve away coverage that people with pre-existing conditions need. As Kaiser Health News reports:
Somebody with cancer might be able to buy insurance but find it doesn’t cover expensive chemotherapy. A plan might pay for opioids to control pain but not recovery if a patient became addicted. People planning families might find it hard to get childbirth coverage.
The Senate bill also retains a proposal to eliminate all federal funding for Planned Parenthood, for one year. The feds never paid for abortions; this is money the organization uses for breast exams, contraception and testing for sexually transmitted diseases.
5. The Senate Bill Still Ignores Health Care’s Real Problem: Cost
The frustrations that many voters have with the Affordable Care Act are understandable. Very little in that law reduced health care spending, or got at the root causes of excessive charges -- though the ACA did slow down the growth rate compared to previous years.
It’s a valid criticism to point out that premiums continued to rise under the ACA, and quite sharply in some places. If you don’t qualify for any of the ACA assistance to shield you from those price increases, you -- or your employer -- are paying those increases out-of-pocket. It’s a difficult and chronic pre-existing condition of American health care.
If you are interested in learning more about how the U.S. health care system became so expensive for patients, I recommend this book.