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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.