The GOP Healthcare Bill is revealed at last
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| Source: J. Scott Applewhite/AP |
Senate Republicans have released a draft of their Healthcare Bill - the promised updated Obamacare/Affordable Care Act replacement - and we've had some time to go through the details to see just what's in it.
NPR has, true to form, quickly come out with their own step-by-step breakdown of the basics, including under the Affordable Healthcare Act (Obamacare/ACA), the House "American Healthcare Act" (AHA), and the Senate's latest "Better Care Reconciliation Act" (BCRA).
See also The Hill's shorter breakdown and a much meatier one from Politifact (warning: Autoplay-videos on both)
The only thing missing, and probably pertinent, is what the system was like before Obamacare, but I'd like to add some commentary as well. Here are the sections as they presented them:
People Under 26:
Obamacare allowed people in this age group to stay on their Parents' Insurance up to 26, or buy their own - all three plans keep this, but before Obamacare young adults were forced off their Parents' plans several years younger.
No change
Adults Under 65:
This is a long one - Obamacare (the current law) created Exchanges for individuals to buy insurance, capped Premiums at costing 9.5 percent of the buyer's income, and capped Seniors close to 65 at no more than three times what they would have paid if they were younger. Rates are calculated in part based on age and tobacco use, and a combination of Subsidies and Tax Credits apply for people making up to 400 percent (four times) the Poverty Level. Also expanded Medicaid to many very low-income Americans.
The House AHA provides Tax Credits based solely on age, and those tax credits are capped at $4,000 per year. No Subsidies. Older Americans still too young to be on Medicaid can now be charged up to five times what younger Americans are, and Medicaid sees cuts starting in 2020.
The Senate BCRA is the same as the House bill, except it adds back some Subsidies for people making up to 350 percent (3.5 times) the Poverty Level. It also allows those between 59 and 64 to have Premiums costing up to 16.2 percent of their income. It keeps the Medicaid cuts, and actually makes deeper cuts, but pushes them back one year to 2021.
Some changes over the ACA, minor changes/details between AHA and BCRA. Both GOP replacements appear designed to cost Americans more. The cuts to Medicaid are actively going to kick people off of their insurance, which by itself will raise Premiums rather than lower them.
Low-Income Nursing Home Residents:
Obamacare covers "Skilled Nursing Care" up to 100 days under Medicare, and Medicaid is available based on income.
Under the AHA, there's no official change, but Medicaid cuts affect this.
The BCRA seems to have slightly milder cuts to Medicaid, but there are still cuts to Medicaid.
Cuts to Medicaid are a consistent part of both the AHA and BCRA, and while they both keep the covered 100 days, for those who wind up needing more Medicaid cuts may affect them.
Pre-Existing Conditions:
This is one of the biggest, core principles of Obamacare - Coverage cannot be denied or cost more based on Pre-Existing Conditions.
The AHA allows States to "get permission" to let Insurers charge more for some pre-existing conditions, and exclude some people entirely as uninsurable. States would also have access to a pool of money for these more expensive cases, but details are unclear.
The BCRA pulls back the AHA somewhat, requiring that Insurers must cover everyone regardless of health status. However, States can ask permission to reduce "required coverage," or to allow Insurers to offer Insurance plans that cover fewer services or situations. This also allows some leeway in how much Insurers are able to charge people.
This point is huge. This was one of the biggest wins of Obamacare, that people were legally not longer able to be dropped from their Insurance because of an operation, condition, illness, etc. And the final points on what plans could offer are important as well, because many insurers were offering cheaper plans that just didn't cover very much (such as not covering Maternity Care without telling you), which is why Obamacare set up requirements for what the minimum a Plan covered to be sold on healthcare exchanges.
The fact that people can, or ever could, be dropped from their insurance *when they actually need it* is ridiculous to the point of being criminal. The AHA was inexcusable on this count. The BCRA is closer to the mark, but frankly, this is one of the aspects of Obamacare that should be untouched. Even allowing Insurers to charge more will result in many people who truly need their healthcare off it.
Planned Parenthood:
Obamacare reimbursed patients for Planned Parenthood Services (NOT Abortions)
Both the AHA and BCRA will not reimburse patients for these visits for one year after it/they are signed into law.
This is an attempt to remove Planned Parenthood and punish the organization for their perceived violation of Conservative values. Ostensibly, this is about banning Abortion (which none of this funding goes to anyway), but the AHA/BCRA hold on this reimbursement is likely to cause small public health crises all across the US, and is terrible for Women's Health, especially in poorer communities with limited access.
There is no reason for this.
People with Disabilities:
Under Obamacare, may qualify for Medicare and Medicaid.
The AHA's Waiver system may allow States to deny coverage for Disabilities based on how this law was written.
The BCRA includes cuts to Medicaid which will include cuts to portions covering disabilities.
Cuts to Medicaid go directly against the stated goals of these bills, and will disproportionately affect the elderly, Disabled, and poor.
Mental Health Services:
Obamacare covered Mental Health Services as Essential Health Benefits that plans are required to offer.
Under the AHA, Mental Health Services are high on the list of items for which States can get a waiver to offer plans that don't cover them.
As for the BCRA, Medicaid will no longer cover MHS after 2019, otherwise same as the AHA.
After all the incidents we've seen across the country, it should be plain as day that providing access to these services for people who need them is a priority. AHA/BCRA cuts here may reduce Premiums, but limit access to what, for some, may be essential care. This is a risky move at best, if not an outright mistake.
The Working Poor on Medicaid:
Obamacare allowed States to choose to expand Medicaid to cover those who are working, but under the Poverty line. 31 States and DC chose to do so.
Under the AHA, the Medicaid Expansion phases out.
Under the BCRA, the Medicaid Expansion phases out between 2021 and 2023, with "further reductions" after that. There also is a "trigger clause" for eight States (Arkansas, Illinois, Indiana, Michigan, Montana, New Hampshire, New Mexico and Washington) which would allow the Federal Government to end the Expansion essentially at-will.
Again, a big attack on Medicaid, and this is one of the biggest parts that will force people off of health insurance. The Trigger Clause is especially nasty, because it could end benefits for those States' programs overnight.
The Wealthy:
Obamacare included some taxes for the Wealthiest Americans to cover the costs of the bill
The House AHA removed the taxes put in place by Obamacare, and also included a $592 Billion Tax Cut, specifically for the wealthy.
The BCRA removes the Obamacare taxes, and keeps the AHA's massive Tax Cut essentially the same.
The Wealthy contributing to this makes sense. The more money someone has, the more they depend on others to earn and maintain it, and it makes sense to include a tax to pay for Obamacare. Particularly since those targeted by the taxes make more than enough money to pay for their own healthcare without changes to the law, while whole families of poorer Americans go bankrupt over medical bills.
The AHA's inclusion of Tax Cuts was - forgive my bluntness - the stupidest policy I've ever heard. Repealing the Obamacare taxes was one thing, but making their healthcare bill cost MORE even after the cuts to Medicaid? And of all things for the BCRA to keep in it, this is a handout to the wealthy, and will hurt the majority of Americans by raising Premiums for their insurance.
Further, this will cost the government more, because the BCRA keeps some of Obamacare's subsidies to keep Premiums down, but with the massive Tax Cut now has no way to pay for those Subsidies.
Mandates:
Obamacare includes penalties for anyone who doesn't buy - or otherwise get - insurance.
The AHA and BCRA remove those penalties, and the mandate for getting insurance.
The Mandate is a mixed bag. On the one hand, the idea that you want *everyone* insured so it's cheaper for everyone absolutely makes sense. On the other, it's an especially heavy-handed way to go about it, and made a lot of people especially angry.
That said, without some sort of mandate or incentive to get insurance, the whole concept falls apart, and you wind up with many fewer, sicker people on insurance, which will send Premiums straight through the roof.
Let's recap -
So at the end of the day, who wins? Insurance Companies get big boosts here, having the option to charge those near-retirement considerably more, and the chance to offer "cheaper" plans by having plans that don't cover essential services.
The Wealthy win big, with a whopping Tax Cut.
And who loses?
Well, everyone else. Anyone on Medicare or Medicaid is going to feel those cuts quickly - not to mention getting rid of the Medicaid Expansion will drop a huge number of people from their Insurance. Anyone relying on Subsidies and Tax Credits to pay their Premiums will have a hard time doing so, although less so than under the BCRA than the AHA. Those with pre-existing conditions are in trouble again, because even though Insurers are require to offer coverage, they're once again free to crank up prices on those who need insurance the most. And cutting non-Abortion Planned Parenthood services this way is terrible for teen pregnancy and general family planning - and the places that need those services most are going to get hit the hardest.
In short though, we all lose. Because at the end of the day this Bill does little or nothing to fix the actual problems with Obamacare and our Healthcare system in general. Instead it takes the best parts of Obamacare - the ones that are very popular - and punches holes right through them, while pouring money on Insurers and the wealthy.
Whatever the final version is, it's a bad bill, that they're trying to get passed in one short week after revealing the details on it. If this passes, a wildly ineffectual GOP Congress gets to claim that they "repealed Obamacare," and say they finally actually did something, before they resort to blaming others for its failure.
That's all for today - please forgive my unusually sharp comments, these particular bills earned some extra ire from me for the sheer audacity of how they're written.
Why again aren't we talking about single-payer?
The only thing missing, and probably pertinent, is what the system was like before Obamacare, but I'd like to add some commentary as well. Here are the sections as they presented them:
People Under 26:
Obamacare allowed people in this age group to stay on their Parents' Insurance up to 26, or buy their own - all three plans keep this, but before Obamacare young adults were forced off their Parents' plans several years younger.
No change
Adults Under 65:
This is a long one - Obamacare (the current law) created Exchanges for individuals to buy insurance, capped Premiums at costing 9.5 percent of the buyer's income, and capped Seniors close to 65 at no more than three times what they would have paid if they were younger. Rates are calculated in part based on age and tobacco use, and a combination of Subsidies and Tax Credits apply for people making up to 400 percent (four times) the Poverty Level. Also expanded Medicaid to many very low-income Americans.
The House AHA provides Tax Credits based solely on age, and those tax credits are capped at $4,000 per year. No Subsidies. Older Americans still too young to be on Medicaid can now be charged up to five times what younger Americans are, and Medicaid sees cuts starting in 2020.
The Senate BCRA is the same as the House bill, except it adds back some Subsidies for people making up to 350 percent (3.5 times) the Poverty Level. It also allows those between 59 and 64 to have Premiums costing up to 16.2 percent of their income. It keeps the Medicaid cuts, and actually makes deeper cuts, but pushes them back one year to 2021.
Some changes over the ACA, minor changes/details between AHA and BCRA. Both GOP replacements appear designed to cost Americans more. The cuts to Medicaid are actively going to kick people off of their insurance, which by itself will raise Premiums rather than lower them.
Low-Income Nursing Home Residents:
Obamacare covers "Skilled Nursing Care" up to 100 days under Medicare, and Medicaid is available based on income.
Under the AHA, there's no official change, but Medicaid cuts affect this.
The BCRA seems to have slightly milder cuts to Medicaid, but there are still cuts to Medicaid.
Cuts to Medicaid are a consistent part of both the AHA and BCRA, and while they both keep the covered 100 days, for those who wind up needing more Medicaid cuts may affect them.
Pre-Existing Conditions:
This is one of the biggest, core principles of Obamacare - Coverage cannot be denied or cost more based on Pre-Existing Conditions.
The AHA allows States to "get permission" to let Insurers charge more for some pre-existing conditions, and exclude some people entirely as uninsurable. States would also have access to a pool of money for these more expensive cases, but details are unclear.
The BCRA pulls back the AHA somewhat, requiring that Insurers must cover everyone regardless of health status. However, States can ask permission to reduce "required coverage," or to allow Insurers to offer Insurance plans that cover fewer services or situations. This also allows some leeway in how much Insurers are able to charge people.
This point is huge. This was one of the biggest wins of Obamacare, that people were legally not longer able to be dropped from their Insurance because of an operation, condition, illness, etc. And the final points on what plans could offer are important as well, because many insurers were offering cheaper plans that just didn't cover very much (such as not covering Maternity Care without telling you), which is why Obamacare set up requirements for what the minimum a Plan covered to be sold on healthcare exchanges.
The fact that people can, or ever could, be dropped from their insurance *when they actually need it* is ridiculous to the point of being criminal. The AHA was inexcusable on this count. The BCRA is closer to the mark, but frankly, this is one of the aspects of Obamacare that should be untouched. Even allowing Insurers to charge more will result in many people who truly need their healthcare off it.
Planned Parenthood:
Obamacare reimbursed patients for Planned Parenthood Services (NOT Abortions)
Both the AHA and BCRA will not reimburse patients for these visits for one year after it/they are signed into law.
This is an attempt to remove Planned Parenthood and punish the organization for their perceived violation of Conservative values. Ostensibly, this is about banning Abortion (which none of this funding goes to anyway), but the AHA/BCRA hold on this reimbursement is likely to cause small public health crises all across the US, and is terrible for Women's Health, especially in poorer communities with limited access.
There is no reason for this.
People with Disabilities:
Under Obamacare, may qualify for Medicare and Medicaid.
The AHA's Waiver system may allow States to deny coverage for Disabilities based on how this law was written.
The BCRA includes cuts to Medicaid which will include cuts to portions covering disabilities.
Cuts to Medicaid go directly against the stated goals of these bills, and will disproportionately affect the elderly, Disabled, and poor.
Mental Health Services:
Obamacare covered Mental Health Services as Essential Health Benefits that plans are required to offer.
Under the AHA, Mental Health Services are high on the list of items for which States can get a waiver to offer plans that don't cover them.
As for the BCRA, Medicaid will no longer cover MHS after 2019, otherwise same as the AHA.
After all the incidents we've seen across the country, it should be plain as day that providing access to these services for people who need them is a priority. AHA/BCRA cuts here may reduce Premiums, but limit access to what, for some, may be essential care. This is a risky move at best, if not an outright mistake.
The Working Poor on Medicaid:
Obamacare allowed States to choose to expand Medicaid to cover those who are working, but under the Poverty line. 31 States and DC chose to do so.
Under the AHA, the Medicaid Expansion phases out.
Under the BCRA, the Medicaid Expansion phases out between 2021 and 2023, with "further reductions" after that. There also is a "trigger clause" for eight States (Arkansas, Illinois, Indiana, Michigan, Montana, New Hampshire, New Mexico and Washington) which would allow the Federal Government to end the Expansion essentially at-will.
Again, a big attack on Medicaid, and this is one of the biggest parts that will force people off of health insurance. The Trigger Clause is especially nasty, because it could end benefits for those States' programs overnight.
The Wealthy:
Obamacare included some taxes for the Wealthiest Americans to cover the costs of the bill
The House AHA removed the taxes put in place by Obamacare, and also included a $592 Billion Tax Cut, specifically for the wealthy.
The BCRA removes the Obamacare taxes, and keeps the AHA's massive Tax Cut essentially the same.
The Wealthy contributing to this makes sense. The more money someone has, the more they depend on others to earn and maintain it, and it makes sense to include a tax to pay for Obamacare. Particularly since those targeted by the taxes make more than enough money to pay for their own healthcare without changes to the law, while whole families of poorer Americans go bankrupt over medical bills.
The AHA's inclusion of Tax Cuts was - forgive my bluntness - the stupidest policy I've ever heard. Repealing the Obamacare taxes was one thing, but making their healthcare bill cost MORE even after the cuts to Medicaid? And of all things for the BCRA to keep in it, this is a handout to the wealthy, and will hurt the majority of Americans by raising Premiums for their insurance.
Further, this will cost the government more, because the BCRA keeps some of Obamacare's subsidies to keep Premiums down, but with the massive Tax Cut now has no way to pay for those Subsidies.
Mandates:
Obamacare includes penalties for anyone who doesn't buy - or otherwise get - insurance.
The AHA and BCRA remove those penalties, and the mandate for getting insurance.
The Mandate is a mixed bag. On the one hand, the idea that you want *everyone* insured so it's cheaper for everyone absolutely makes sense. On the other, it's an especially heavy-handed way to go about it, and made a lot of people especially angry.
That said, without some sort of mandate or incentive to get insurance, the whole concept falls apart, and you wind up with many fewer, sicker people on insurance, which will send Premiums straight through the roof.
Let's recap -
So at the end of the day, who wins? Insurance Companies get big boosts here, having the option to charge those near-retirement considerably more, and the chance to offer "cheaper" plans by having plans that don't cover essential services.
The Wealthy win big, with a whopping Tax Cut.
And who loses?
Well, everyone else. Anyone on Medicare or Medicaid is going to feel those cuts quickly - not to mention getting rid of the Medicaid Expansion will drop a huge number of people from their Insurance. Anyone relying on Subsidies and Tax Credits to pay their Premiums will have a hard time doing so, although less so than under the BCRA than the AHA. Those with pre-existing conditions are in trouble again, because even though Insurers are require to offer coverage, they're once again free to crank up prices on those who need insurance the most. And cutting non-Abortion Planned Parenthood services this way is terrible for teen pregnancy and general family planning - and the places that need those services most are going to get hit the hardest.
In short though, we all lose. Because at the end of the day this Bill does little or nothing to fix the actual problems with Obamacare and our Healthcare system in general. Instead it takes the best parts of Obamacare - the ones that are very popular - and punches holes right through them, while pouring money on Insurers and the wealthy.
Whatever the final version is, it's a bad bill, that they're trying to get passed in one short week after revealing the details on it. If this passes, a wildly ineffectual GOP Congress gets to claim that they "repealed Obamacare," and say they finally actually did something, before they resort to blaming others for its failure.
That's all for today - please forgive my unusually sharp comments, these particular bills earned some extra ire from me for the sheer audacity of how they're written.
Why again aren't we talking about single-payer?
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