The Senate has finally posted its draft of the American Health Care Act, which it's calling the Better Care Reconciliation Act. This is the bill to repeal and replace Obamacare, which Republicans have been threatening to do since it passed and Donald Trump harped on during his campaign. The House passed a ridiculously unpopular repeal bill by a narrow vote on May 4; since then Republicans have drawn a tremendous amount of scrutiny for drafting the bill in secret, rather than in an open committee like how the Obamacare was written.
Lots and lots of people hated the House bill in its first, cruel iteration—which didn't even get a vote—and it only got worse once conservatives lobbied to let states opt out of covering essential health benefits and allow them to charge sick people more. Donald Trump reportedly said that the House bill that passed was "mean" and urged Senators to be more generous in their draft and "add more dollars to healthcare." No matter how Republicans try to spin the Senate bill, know that it is not generous (unless you're rich and excited about tax cuts) and it is absolutely still mean; perhaps even meaner than the House bill. And it is not better care. It would result in millions of people losing insurance and people paying higher premiums and deductibles for plans that cover less.
Here's exactly how the Senate bill stacks up to the House bill and Obamacare, starting with the much-derided provision that every American have health insurance or pay a tax penalty, known as the individual mandate.
Individual mandate: Totally gone, meaning sick people will pay even more.
House bill: Removes the Obamacare requirement that every American have health insurance even if they're healthy and replaces it with a continuous coverage provision—a penalty on purchasing a new plan after a coverage lapse of longer than 63 days. Starting with the enrollment period for 2019, people who didn't have continuous coverage the previous year (if, say, they changed jobs) would be subject to a penalty of 30 percent on their premiums for one year when they re-enroll.
Senate bill: Removes the individual mandate and surprisingly does not include the House's continuous coverage provision. Which is to say that there appears to be no replacement for the mandate at all. The bill also repeals the rule that companies with 50 or more employees must offer insurance, aka the employer mandate.
What it means: Republicans really hated this Obamacare rule but even the House provision that would charge people 30 percent more if they tried to re-enroll would discourage people from signing up unless they're sick, thereby keeping healthy people out of the insurance market. You need healthy people to buy insurance for the system to work. With zero requirement that people have insurance, only sick people are going to buy it, making it more expensive for them. But of course, Republicans don't see it this way.
Medicaid: 10 million people will lose it.
House bill: Obamacare expanded Medicaid from being open to people earning 100 percent of the federal poverty level up to people earning 138 percent of the FPL; 31 states and Washington DC opted in. The House bill would allow people in states that expanded Medicaid to continue to enroll in the program through January 1, 2020, but changes open-ended Medicaid funding to "per capita caps," aka block grants, in 2020 based on the number of people enrolled in the program in 2016. If states have to spend more than what they're given, they'll have to pay the difference.
Senate bill: Would phase out additional funds for the Medicaid expansion from 2020 to 2024, when the expansion would effectively end. It keeps the per capita caps but after 2025, it would tie funding pools to a different, smaller growth rate than the House bill did, which would mean much less money over time. Former Medicaid director Andy Slavitt also pointed out that eligibility for the individual insurance market starts at 0 percent of the federal poverty line in the Senate bill, which means states could technically eliminate Medicaid and funnel people into the exchanges with no help. There are also optional work requirements for Medicaid enrollees who aren't pregnant, disabled, or elderly.
What it means: Dragging out the phase-out still has the same result: 10 million people who gained insurance coverage via the Medicaid expansion will lose it. But eight states would see the expansion end immediately in 2020, because they have laws that halt the expansion if the government makes any cuts to Medicaid spending. These so-called trigger states are: Arkansas, Illinois, Indiana, Michigan, Montana, New Hampshire, New Mexico, and Washington. Also remember that Trump famously promised not to cut Medicaid.
Preexisting conditions: Protected, but in name only.
House bill: It said states could waive the current rule that insurers can't charge people more for having preexisting health conditions, but only for people who have a lapse in coverage; insurers couldn't reevaluate the plans of people who currently have insurance.
Senate bill: Does not include this provision.
What it means: The preexisting rule made insurance cheaper for sicker people but more expensive for healthier people, so healthy people didn't like it. Technically the Senate bill means people with preexisting conditions couldn't be charged more for their health insurance plan's premiums, the monthly cost of having insurance. Butttttt see the next section because this is a red herring.
Essential health benefits: Getting depressed, pregnant or sick could mean bankruptcy depending on your state.
House bill: It let states opt out of the requirement that they cover the same ten "essential health benefits" or EHBs, set by Obamacare, which include maternity care, prescription drugs, and mental health and addiction treatment. States could opt out with waivers, known as 1332 waivers.
Senate bill: Dramatically expands the state waiver program, and crucially and shockingly, removes the requirement that states applying for waivers have to guarantee to cover as many people with coverage that's as affordable and as comprehensive. Governors can also seek these waivers without consulting their state legislatures, aka the elected representatives of the people the waivers would affect.
What it means: True, a person with cancer couldn't be denied insurance or charged more for a plan, but it's possible that their state would only offer plans that don't cover cancer treatment. Same goes for people with mental health conditions who need inpatient or outpatient care. And this provision would once again permit price discrimination against women simply because they can get pregnant and give birth and men can't. In states that waive EHBs, insurers could sell plans that appear cheaper on their face, but would end up costing people more in the long run if they need anything more than bare-bones coverage. Letting states choose their own EHBs—saying that certain benefits are no longer considered essential—also means that Obamacare's ban on lifetime and annual limits would no longer apply to those benefits. And if you think this doesn't affect you because you have insurance through work, know that letting states change EHBs would also affect employer-based insurance for millions.
Tax credits: Smaller, stingier, so people pay more for less coverage.
House bill: Offered tax credits based on age instead of Obamacare's income- and location-based subsidies for purchasing health coverage, which meant that people in rural areas where healthcare is more expensive would have suffered.
Senate bill: Would replace the House bill's flat tax credit with credits based on local premiums. But fewer people would be eligible for these subsidies: Currently they're available for people making less than 400 percent of the federal poverty level ($47,550 for an individual), but would be limited to 350 percent of the FPL ($41,580). The tax credits would also be cut by about 15 percent and shifted so that younger people pay less and older people pay more as a percentage of their income compared to Obamacare. Another thing to be aware of: The bill only funds cost-sharing reductions (payments to insurers to help with deductibles) through 2019, so deductibles would increase in 2020. Many insurers have cited uncertainty about CSR payments as their reason for raising premiums or dropping out of the market altogether.
What it means: People will may more for plans that cover less. The end.
Planned Parenthood provision: Will block women from contraception and cancer screening. Is also possibly illegal.
House bill: Impose a one-year freeze on any Medicaid reimbursement to healthcare providers like Planned Parenthood that perform abortions for reasons other than rape, incest, or to save the life of the mother.
Senate bill: The same.
What it means: The Hyde Amendment already prohibits federal funds from being used outside these cases, so all this provision does is dictate where women with Medicaid can get other important healthcare services including birth control and cancer screenings. Federal appeals court judges have ruled that this kind of exclusion is illegal. Many aides also believe the provision would violate the "Byrd Rule," which says that items in a reconciliation bill have to affect the federal budget; it might be cut by the Senate parliamentarian.
Insurance coverage of abortion: Limited enough to endanger women's health.
House bill: Would prevent people from using premium subsidies to purchase insurance plans that cover abortion other for reasons than rape, incest, or to save the life of the mother. Meaning if a woman faces health complications from the pregnancy, her insurance wouldn't cover the procedure until she's dying.
Senate bill: The same.
What it means: As a new Tonic documentary outlines, restricting access to abortions in cases where the fetus is nonviable or the woman's health is affected puts women in the tough position of paying large sums out of pocket or waiting until they develop a life-threatening complication. Neither is good.
Older people provision: Adds insult to injury.
House bill: Allow insurers to charge older people premiums of up to five times as much as younger people; the current limit is three times as much. This provision is known as age-rating.
Senate bill: The same.
What it means: Older people get insult to injury with this age-rating change, which is on top of reduced subsidies compared to Obamacare and cuts to Medicaid, which covers half of nursing home care in the US.
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