William Rivers Pitt |
Ruthless, Soulless, Vicious: Three Reasons the Senate GOP's ACA Replacement Is
a Disgrace
The Senate's answer to the
House bill to repeal the Affordable Care Act -- cheerily titled "The Better Care Reconciliation Act of 2017" -- hit my
desk like a bag of dung late Thursday morning. As I read through its largely
inscrutable text, I started flashing back to junior high school and the first
time I tried to read Shakespeare in the raw. Take, for one example, this nugget
from p. 74, sec. 1903A, lines 18-24: "1903A ENROLLEE. -- The term '1903A
enrollee' means, with respect to a State and a month and subject to subsection
(i)(1)(B), any Medicaid enrollee (as defined in paragraph (3)) for the month,
other than such an enrollee who for such month is in any of the following
categories of excluded individuals …"
Clear as mud, Mr. McConnell.
After a couple of false starts, I found my groove and with slowly dawning
horror realized I was reading one of the most ruthless, soulless, vicious
documents ever put to print. While not as bloodthirsty as the House version it
seeks to correct, the Better Care Reconciliation Act is a genuinely cruel piece
of work that will deliver millions of people to the gutter or the grave.
1. The Dismantling of Medicaid
Let's start with a baseline:
Some 20 percent of Americans are enrolled in Medicaid; 39 percent of children
in the US are enrolled in Medicaid; 49 percent of births are covered by
Medicaid; and a full 64 percent, or nearly two-thirds of nursing
home patients, are covered by Medicaid.
Here's the treatment Medicaid
gets in this reconciliation bill: "Beginning with fiscal year 2020, any
State (as defined in subsection (e)) that has an application approved by the
Secretary under subsection (b) may conduct a Medicaid Flexibility Program to
provide targeted health assistance to program enrollees."
And: ''(A) FEDERAL PAYMENT. --
Subject to sub-paragraph (D), the Secretary shall pay to each State conducting
a Medicaid Flexibility Program under this section for a fiscal year, from its
block grant amount under paragraph (2) for such year, an amount for each
quarter of such year equal to the Federal average medical assistance percentage
(as defined in section 1903A(a)(4)) of the total amount expended under the
program during such quarter, and the State is responsible for the balance of
the funds to carry out such program."
The Better Care Reconciliation
Act is a genuinely cruel piece of work that will deliver millions of people to
the gutter or the grave.
In short, control of Medicaid
will devolve to the states, essentially ending the program as we have known it.
States will not be allowed to expand Medicaid after three years, a large
sticking point for several GOP senators who are still on the fence. States will
be responsible for at least a portion of the costs beyond what is provided by a
federal block grant, and as described in later language, can opt out of the
whole thing whenever they choose. The amount of that block grant will diminish
over time after 2021, which lessens the immediate impact on Medicaid but does
far more damage to the program in the long run. Medicaid itself will
essentially cease to exist after 2025.
That last piece is a clever
bit of sleight-of-hand often practiced on 42nd Street in New York City by guys
with three nutshells and a pea: Stretching out the attack on Medicaid over a
longer time period leavens the headline-grabbing conclusions that will be
reached by the Congressional Budget Office's score, which is slated to be released on Monday. Any way
you slice it, tens of millions of people will take it right in the teeth, and
many of them are the poorest and neediest among us.
2. Attacks on Elderly People,
Women and Working People
Under this new reconciliation,
insurers will be allowed to charge older policyholders as much as five times
more than younger policyholders. Tax credits for insurance will be based on
age, geographic location and income, but will only be applied to the shabbier
plans available, and will end in 2020 if President Trump doesn't cancel them
sooner, which he will have the power to do. States will be allowed to alter the
definition of an "essential health benefit," so services like
emergency care and prenatal care could face the chopping block.
In the bill, Planned
Parenthood is stripped of federal funding, a direct attack on basic, necessary
reproductive health care. This amounts to yet another front in the GOP’s
long-standing quest to relegate women to second-class status in the US, and if
successful, will represent a huge victory for the anti-choice right wing.
Planned Parenthood, crucially, offers abortion, but it also addresses many
other needs. It performs cancer screening and offers birth control, along with
a wide assortment of other health care services, often for women who cannot
afford health insurance or OBGYN care. If this provision is allowed to stand,
it will be a devastating blow.
Medicaid itself will
essentially cease to exist after 2025.
One woefully under-reported
aspect of this bill is the fact that the employer mandate to provide insurance
is gone. This has the potential to do grave damage to the middle-class and
working-class families who depend on employer-provided insurance. With no
financial incentive to provide employee coverage, and plenty of financial
incentive to denude or do away with employee coverage entirely, look for a grim
number of businesses, large and small, taking advantage of this provision to
the detriment of millions.
3. The Loot
And then, of course, there is
the loot. Beyond the $800 billion that will be stripped from Medicaid over time
and shuttled to the rich, the guts of this reconciliation bill are bursting
with repealed taxes that will favor the wealthy and the health care industry
itself. To the delight of John Boehner and presumably Trump as well, p. 29,
line 17, sec. 118 repeals the "Tanning Tax," but a whole battalion of
other tax repeals follow like the tolling of a dinner bell for the ravenous
few.
This reconciliation bill is so
ruthless that it inspired former President Obama to denounce it in a large Facebook missive on Thursday
afternoon. "Simply put," he wrote, "if there's a chance you
might get sick, get old, or start a family -- this bill will do you harm. I
still hope that there are enough Republicans in Congress who remember that
public service is not about sport or notching a political win, that there's a
reason we all chose to serve in the first place, and that hopefully, it's to
make people's lives better, not worse."
The latter sentiment reminded
me of a recent comment by Charles P. Pierce regarding President Obama and the
Republicans: "This may be the final example of the worst part of the Obama
presidency," wrote Pierce, "namely, his persistent, unfounded
belief in the rationality of his political opposition." Anyone who reads
and comprehends the core nature of this bill must, I fear, be forced to agree.
Nice people did not draft this thing, and the tiny slice of the public the
drafters are serving with it couldn't give less of a damn about the damage that
will be done by it -- in fact, many of them will benefit from it.
Will It Fly?
Now that the cat is finally
out of the bag, the central question remains: Will this thing fly? McConnell
has bet every chip he has that moderate Republicans who are wary of the
Medicaid restrictions and conservative Republicans who see this as too much
like the ACA will eventually fall in line, lest the whole thing collapse in
ignominy and wind up around their necks like a rancid albatross in 2018.
McConnell has already made it abundantly clear that if this reconciliation
fails, he intends to move on to other matters.
One woefully under-reported
aspect of this bill is the fact that the employer mandate to provide insurance
is gone.
It's a very tall gamble.
Conservatives like Rand Paul have already attacked the thing, and moderates
like Shelley Capito, Rob Portman and Susan Collins remain very leery over the
current version of the bill. As of Thursday evening, Paul, along with fellow
senators Ted Cruz, Ron Johnson and Mike Lee, had voiced their grave displeasure with the bill as currently
constituted and threatened to vote "No" on anything they deem to be
"Obamacare Lite." They may mean it, or they could just be positioning
themselves for negotiations on the final language that are almost certainly
already underway.
McConnell has 52 Republican
senators in his caucus and needs 50 votes, with Vice President Pence waiting in
the wings to cast a tie-breaking vote if need be. He can't lose more than two.
It will be a close shave. The CBO scoring will hit on Monday, and McConnell has
vowed to bring the bill to the floor next week whether or not he has the votes.
Bear in mind, of course, that
in this day and age, the words "moderate" and "Republican"
seldom find each other comin' through the rye. A "moderate"
Republican today is akin to the snipe, a mythical creature that has been hunted
by millions to no avail. Provisions to address the opioid crisis and to
elongate the assault on Medicaid both made it into the bill as a sop to these wavering
"moderates." There's a lot of talk coming from that quarter right
now, but I suspect these fence-sitters will eventually line up with the
majority leader. It will likely be the hard-liners like Paul who will decide if
this thing lives or dies. The margin is indeed miniscule if, as expected, no
Democrats vote in favor.
It will likely be the
hard-liners like Paul who will decide if this thing lives or dies.
The fate of millions now
stands upon the fulcrum of the coming week. This reconciliation was drafted in
total secrecy, and in the light of day stands as little more than a
smash-and-grab robbery favoring the wealthy and powerful at the brutal expense
of the poorest and weakest among us. With the removal of the employer mandate,
middle-class and working-class families likewise face a future of uncertainty
and pain. That this bill exists at all is an embarrassment to the nation. The
"Better Care Reconciliation Act of 2017" must be cast out with the
refuse like the bag of dung it is.
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