June 29, 2017

Trump claimed the Senate Republicans' version of a health care law would have "heart," but it's still a disaster--and it isn't dead and buried either, writes Christopher Baum .

THE LONG-held Republican dream of tearing down the Obama administration's signature health care law, the Affordable Care Act (ACA), was put on hold this week when the GOP Senate leadership announced that its bill, the Better Care Reconciliation Act (BCRA), would not be put to a vote before Congress' July 4 recess.

Senate Majority Leader Mitch McConnell had been pressing urgently for a vote, but on Tuesday afternoon, he conceded that there was too much opposition among Republicans to pass the legislation. At least five Republican senators had declared their opposition by that point--following McConnell's announcement, three more came out against the bill.

For the moment, Trump and the Republicans are in some disarray. But House Republicans appeared to be in similar state of chaos at the end of March, after the first version of their American Health Care Act (AHCA) was withdrawn without a vote--and just over a month later, they managed to pass an even worse version of the same bill.

This is no victory, merely a reprieve--as protesters who continued to demonstrate on Capitol Hill on Wednesday understood.

Trump with Senate Majority Leader Mitch McConnell in the U.S. Capitol

A protest earlier in the week set the tone for how this deadly proposal to wreck the already damaged health care system should be greeted.

On June 22, several dozen activists organized by the disability rights group ADAPT staged a "die-in" outside of Senate Majority Leader Mitch McConnell's office. In scenes that have already become iconic, the U.S. Capitol Police forcibly removed the protesters, some of whom had left their wheelchairs and laid on the ground as part of the demonstration.

Forty-three people were arrested. No one was seriously injured, but the incident struck a chord with people throughout the country as they struggle for ways to express their bitter opposition to Trump-Ryan-McConnell-care.

The protest also provided--in such images as the unforgettable footage of armed police dragging a disabled woman from her wheelchair--disturbingly apt visual metaphors for the horror that is the BCRA.

DONALD TRUMP said before details of the Senate bill was released that he expected it to have "heart"--in contrast to the House version, which he reportedly described as "mean, mean, mean," though that didn't stop him from celebrating the AHCA when it passed in a White House Rose Garden ceremony.

But "heartless" is a better description for both versions of the Republican proposal to demolish health care and hand over the resulting "savings" to the super-rich in the form of tax cuts.

As it did with the AHCA, the nonpartisan Congressional Budget Office (CBO) analyzed the Senate bill for its projected effects over the next 10 years. The CBO's assessment of the AHCA indicated that the bill would leave an additional 23 million people without insurance by 2026 (compared to projections if Obamacare were to remain in effect). If, instead, the Senate's new proposal was to become law, the CBO's analysis suggests that the increase in the uninsured over projections under the current law would be 22 million people.

This meager reduction--from an enormous number of additional uninsured to a slightly smaller but still enormous number--offers little evidence of "heart."

The core of both bills is a drastic assault on the government's Medicaid health care program for the poor, reversing the expansion under Obama's ACA. The Senate bill proposes somewhat smaller, though still enormous, cuts to Medicaid--$772 billion over 10 years compared to $834 billion in the House plan.

But the Senate's BCRA calls for substantially larger reductions in funds for subsidies for people who purchase non-group insurance--a $408 billion cut compared to $276 billion slashed by the House version.

As a result, the Senate proposal actually goes further in slashing aid for the needy than the House did.

The CBO analysis of the Senate proposal indicates, predictably enough, that those who would fare worst under the BCRA are the poor, the sick and the elderly--in other words, the very people who most need insurance and access to health care. As the New York Times reports:

Under the bill, the budget office said, subsidies to help people buy health insurance would be "substantially smaller than under current law." And deductibles would, in many cases, be higher. Starting in 2020, the budget office said, premiums and deductibles would be so onerous that "few low-income people would purchase any plan." Moreover, the report said, premiums for older people would be much higher under the Senate bill than under current law. As an example, it said, for a typical 64-year-old with an annual income of $26,500, the net premium in 2026 for a mid-level silver plan, after subsidies, would average $6,500, compared with $1,700 under the Affordable Care Act. And the insurance would cover less of the consumer's medical costs. Likewise, the report said, for a 64-year-old with an annual income of $56,800, the premium in 2026 would average $20,500 a year, or three times the amount expected under the Affordable Care Act.

THE SENATE bill does, unlike the House version, retain Obamacare's requirement that insurers offer the same premiums to people with pre-existing conditions as to those without them.

However, as under current law, this requirement would apply only to "essential health benefits." As Topher Spiro notes in the Washington Post, the BCRA follows the House bill in allowing states to decide for themselves which health benefits are considered "essential." For any treatment not on that list, insurers would be free to charge higher premiums to include them in coverage, place lifetime coverage limits and so on.

Thus, unless the treatment for a particular pre-existing condition happens to be listed as an essential health benefit in the state in question, the apparent protection offered by the Senate bill would, in fact, be nothing of the kind.

As a final example of the kind of "heart" shown by the BCRA, consider how the Senate's "continuous coverage" proposal compares to the one put forward by the House.

Both bills eliminate Obamacare's "individual mandate," the provision that requires everyone not covered by an employer-provided plan to purchase insurance from private companies or else pay a tax penalty.

But the Republicans' health care proposals would instead penalize people who try to obtain insurance after having gone without it for three months or more. The idea, as with the individual mandate, is to create an incentive for even young and healthy people to pay for continuous health insurance coverage, whether or not they think they need it.

Under the House plan, insurance providers would be permitted to add a surcharge on premiums of 30 percent for a full year for anyone who buys insurance after having gone 63 days or more without coverage.

As under Obamacare, the consumer would pay a penalty for not having insurance--but under the House plan, this penalty would be assessed not at tax time, but at the point when the consumer tries to buy insurance--presumably because now they need it. Note also that the penalty goes not into the public coffers--where it might, at least in theory, be used in a way that benefits the community--but directly into the pockets of the insurance company.

This House version was bad enough. But the Senate, quite literally as an afterthought, hit upon an even nastier solution.

As Russell Berman reports in the Atlantic, the BCRA originally didn't contain any continuous-coverage provision at all, but this omission was pounced on by analysts, and Republican senators duly produced an amendment to rectify the oversight.

Under the new Senate plan, people who attempt to buy insurance after going 63 days without coverage will not be forced to pay a surcharge--but instead will have to wait six months before coverage will take effect.

This, then, is the Republican Senate's idea of a health care bill with "heart": Having guaranteed that coverage will be ruinously expensive for those most in need of it, and also that many people will be unable to pay for insurance even if they want it, the BRCA would further penalize those who finally reach the point where they decide they can no longer do without insurance--by making them wait six months for the coverage they will pay an inflated price for.

HEARTLESSNESS FROM Republicans is nothing new. Mitch McConnell and his cronies were no doubt dreaming of these measures long before Donald Trump oozed his way into the White House.

But Trump seems to have freed many prominent Republicans from feeling the need to maintain any pretense about what they are trying to achieve. Following Trump's lead, they make demonstrably false statements about their actions, in an offhand manner that suggests they don't really believe what they're saying anyway--and then, openly and unapologetically, go about their business of destroying social programs, abandoning the sick and needy, and handing the "savings" to the wealthiest segments of U.S. society.

Of course, McConnell's failure to bring his health care bill to a vote shows that there are differences among Republicans. But the disagreements are over details--and as in the House debate on health care, a significant number of Republican senators opposed the BCRA because they didn't think it went far enough in wrecking and looting Medicaid.

A handful of senators, including Rand Paul of Kentucky and Ted Cruz of Texas, criticize the proposal championed by McConnell for leaving the basic structure of Obamacare intact, and thus falling short of the promised objective of "repeal and replace."

On the other side are a handful of less reactionary Republicans--it's hardly accurate to call them "moderates," as many in the media do--such as Susan Collins of Maine, who do object to the drastic cuts to Medicaid and health care subsidies for the poor, at least at the trillion-dollar level in the BCRA.

No points for guessing which opponents of the new bill are facing the most pressure. Of course, it's the ones who worry that the Republicans are on the verge of causing a health care catastrophe that will come back to haunt them in the future.

Right-wing groups have been leaning on lawmakers to get the health care bill passed. For instance, the billionaire Koch brothers' network of donors and investors is threatening to withhold support for Republican politicians "until [they] get some things done"--one of those "things," of course, being to "[g]et Obamacare repealed and replaced."

This pressure has also gotten personal. Earlier on the day that McConnell called off the vote on the BCRA, the pro-Trump organization America First Policies launched a $1 million television and radio ad campaign against Sen. Dean Heller of Nevada, one of the few other Republicans to oppose the bill for doing too much damage to the health care system.

Heller is expected to face a tough re-election campaign in 2018, which makes the ad campaign, as Politico observed, "a stunning act of retribution against a politically vulnerable member of the president's own party."

The right's strategy may backfire: CNN reports that when Republican senators met with Trump in the White House on Tuesday evening to "air their grievances...and chart a path forward", several commented that the attack ads against Heller "aren't helping."

But don't think that the momentum is flowing against the hard right. If Senate Republicans do manage to get their act together and pass a health care bill, we can be fairly certain that--as happened with the AHCA--it will be the hard-liners who are appeased. "BCRA 2.0," if and when it appears, will surely be even worse than the version on offer now.

AS THIS battle over the future of health care continues, we have to be clear not just about what we're fighting against, but what we're fighting for.

The efforts of progressive groups such as Our Revolution, which organized people to call their senators and urge them to vote against the BCRA, may have played a role in swaying some of the less reactionary Republicans to voice criticisms of the bill.

But phone calls alone are never enough. We need mass mobilization, so that politicians everywhere can see our faces and hear our voices as we declare that these assaults on our already-inadequate health care system won't stand. The grassroots protests at town hall events around the country played an important part in showing the developing bitter opposition to Trumpcare outside Washington.

And protesting what we're against is only part of the job. We can't be content, as far too many liberal political leaders seem to be, to merely defend the status quo. We must look beyond preserving Obamacare, whose fatal reliance on private insurance markets is what put Republicans in the position to do even more damage to health care.

The only rational solution is a truly universal health care system--a single-payer, "everybody in, nobody out" program in which private insurance plays no role.

And now the Democrats have proven once again that they will bargain away this goal. In California, the state Senate overwhelmingly passed legislation to create a single-payer system for all residents--but the leader of the Democratic-controlled State Assembly announced he would refuse to allow the measure to come to a vote.

With a 55-25 majority in the Assembly, the Democrats could easily have engineered a victory if they desired it.

The speaker's nonsensical explanation for his action: Supporters of single-payer should stop trying to pass the system they want in California and instead concentrate on defending the system they don't want at the national level.

This shows, if any more evidence were necessary, that we can't rely on the Democratic establishment to fight for the health care system we need.

Neither Trumpcare nor Obamacare will do--we must organize against the attacks underway in Washington, but with a vision of making health care a right, not a privilege, for all.