If Americans think their country is divided now, they better hope the runaway train that is the Senate’s secret bill to destroy government-assisted healthcare has a crash landing.
That’s because the little that’s known about the Senate bill—with its revisions to a House-passed package to repeal Obamacare, eviscerate Medicaid funding and force it to ration care, and give the rich a tax cut—will further divide the country along red and blue lines.
The states that will take the biggest hits and be pushed to reel in safety nets for the poor and vulnerable tend to be blue. That’s the conclusion of a handful of analyses this year that looked at growth in uninsured populations and economic impacts like job losses. Most red states, in contrast, most of which did not expand safety nets or assist the feds in offering subsidies to make insurance more affordable, are more likely to see their health systems continueslipping backwards.
That’s already the case across the Southeast, which pays emergency room doctors the most in the country, a reflection of its needs and regimens. While the GOP may return the nation to an underdeveloped South and a modernized North and West, blue states that tried to help vulnerable populations will take the harshest hits.
There’s a lot of data on these trends. A March report from the Urban Institute is particularly incisive. Looking at which states would be hardest hit by imposing caps on Medicaid spending, the report found a clear blue-red split. The top five states that would see these reductions are New Jersey (20.6 percent), Colorado (20.1 percent), Washington (19.1 percent), Oregon (16.4 percent) and Maryland (16.3 percent). On the opposite side of the spectrum, the states seeing the smallest Medicaid cuts were Wisconsin (2.0 percent), Wyoming (3.1 percent), Nebraska (3.3 percent), Mississippi, Missouri and South Carolina (3.5 percent) and Florida (3.6 percent).
The Dismal Politics
The red-blue fissures and pending mass victimization haven’t been discussed much, because most of the analyses of who would be hurt by the House’s bill have been age-based and broken down by how people get their healthcare—via government programs, employers or as individuals buying it on the private market (including with federal Obamacare subsidies). But you can be sure Senate Republicans, led by the endlessly conniving Mitch McConnell, are absolutely aware of who will be hurt the most by repealing Obamacare and turning Medicaid into a per-capita grant program starting in 2020.
We’ll turn to the analyses in a moment, but first we must note how Senate Republicans are reverting to their most thuggish selves by writing the health bill in secret, holding no hearings and plotting to use Senate fast-track rules bring it to the floor the last week in June in a way that precludes debate. (In contrast, before the Senate passed Obamacare in 2009, it had 36 days of hearings, 18 days of committee work and 26 days of floor debate.)
Today, Senate Republicans on McConnell’s secret bill-writing committee are neither willing nor able to say what’s in their bill—except that it’s not a start-from-scratch effort to replace the House-passed bill. Vox.com’s reporting team cornered members of the Senate committee late this week and not a single senator could articulate what they were doing—just as they all said they were powerless to stop this train. (Remember, the GOP is running this show.)
It’s hard to know who or what to believe. Sen. John Boozman, R-AR, may have been the most candid when he replied, “Well, we don’t have a bill. That’s what we’re working on. The reason we’re working really hard to come up with a bill is to solve some of the problems of Obamacare… We’re trying to come up with a solution that makes things more affordable.” Beyond that, no specifics were shared. None of the senators interviewed, however, mentioned a word about cutting medical and insurance industry profits.
Sen. Lisa Murkowski, R-AK, like all the women in the body, was not given a seat at the drafting table. The GOP has 52 senators and the vice-president can vote to break a tie. “The plan the House laid down does not help Alaska. It does not help decrease their costs, and it does not help increase their access,” she told Vox, and then hedged. “So the question is whether or not what is being built on the Senate side is going to better reflect that. My hope is that it will.”
The rumors are already flying on how McConnell can finesse this bill to passage using the Senate’s arcane rules. He can put out an imposter bill on Monday, June 26. The Senate has to wait 20 hours before taking any further action. Then it can start 20 hours of debate on that shell—10 for senators on each side—and then McConnell can swap in a complete substitute amendment that nobody has read, analyzed, debated on Tuesday with a vote that date or Wednesday.
What’s the likelihood of that? What was the likelihood of McConnell blocking Judge Merrick Garland’s nomination to the Supreme Court for nearly a year? The GOP leader surely knows that the more the public is aware of what Republicans are lining up to do, the more the Senate will face a tidal wave of protests.
The Dire Details
The most recent big-picture analysis to emerge this week came from Paul Spitalnic, the chief actuary at the federal Centers for Medicaid and Medicare Services, which looked at the “estimated financial effect of the [House-passed] American Health care Act of 2017.”
Seen nationally, if the House bill became law, an “additional 4-6 million people” would become uninsured next year and in 2019, the CMS report said. About 2 million would stop buying insurance now required by Obamacare’s mandate, 1-2 million would lose it via their employers, and 1 million would see Medicaid (state-run health care for the poor) drop them due to “more frequent eligibility redeterminations, the repeal of retroactive eligibility, and optional State work requirements for adults.”
The numbers of newly uninsured would double by 2020 and double again six years later. “For Medicaid, the change in eligibility for adults under the AHCA relative to current law is anticipated to reduce the number of Medicaid enrollees by roughly 4 million in 2020 and by 8 million by 2026,” CMS said. “For employer-sponsored insurance, the continued impacts regarding the choice of employers to offer coverage and the choice of employees to take coverage result in 3 million fewer people with such insurance by 2026.”
The reason Medicaid would see the biggest cuts, CMS said, is the House bill would start paying states “per capita” subsidies in 2020. States would then have to ration care, raise taxes or a mix of the two. Now, the way the House tried to sell its bill was by saying it would cut costs for younger people. But that bit of generational warfare bait isn’t accurate, according to a new study from the Center for Budget and Policy Priorities.
Millions of people of all ages would lose, CBPP found. “About 3 million children would lose coverage, increasing the uninsured rate for children by about 50 percent. 6.4 million young adults (age 19-29)—about 1 in 8 people in this age group—would lose coverage. 8.2 million middle-aged people (age 30-49) would lose coverage, increasing their uninsured rate by 84 percent. 5.1 million older adults (age 50-64) would lose coverage. The uninsured rate for this group would more than double, the largest percentage increase for any age group.”
A big feature of the House bill—which is expected to remain in the Senate—is deregulating the health insurance industry. There were plenty of comments by Republican senators in the Vox piece about restoring “freedom” to insurance markets. What does that freedom look like? According to the Kaiser Family Foundation, only 25 percent of individual market plans in 2013—before the minimal coverage requirements of Obamacare took effect—covered maternity care, 55 percent covered substance abuse services and 62 percent covered mental and behavioral health. The GOP isn’t just poised to add millions to the ranks of the uninsured, but will start shredding health coverage for millions.
It only gets worse. An analysis by AARP, the American Medical Association, American Diabetes Association and March of Dimes detailed how more than one-quarter of adults below 65—the age federal Medicare kicks in—have pre-existing conditions, which will cost them a lot more for insurance because they will be shunted into high-risk pools.
“More than 52 million Americans (27 percent of the under-65 population) have a pre-existing condition: More than 29 million have diabetes; more than 1.6 million are diagnosed with cancer annually; more than 15 million adults have cardiovascular disease,” the groups said, explaining what was in store for these individuals on the private market. “Americans with pre-existing conditions could face premiums of $25,477 through high-risk pools. Because of an ‘age tax’ in the AHCA, older Americans could see annual insurance premiums rise dramatically: A 64-year-old earning $25,000 a year could see premiums increase by $7,000. In 2015, half of Americans ages 50-64 buying insurance in the individual markets [not employer-provided] have incomes of $23,500 or less.”
The advocacy groups put a human face on the $839 billion in Medicaid cuts in the House-passed bill: “In 2017, more than 74 million low-income Americans got health coverage through Medicaid and CHIP [Children’s Health Insurance Program], including: More than 6 million people over 65; more than 10 million people with disabilities; more than 37 million children. Medicaid and CHIP cover 3 in 5 nursing home residents and 2 of 5 people with disabilities in the U.S.; 77 percent of Medicaid enrollees in the U.S. are in working families.”
A Red War On Blue America?
A handful of analyses try to see which states would be hit the hardest by repealing Obamacare and shrinking Medicaid. In January, a panel of medical and financial experts did a deep dive for WalletHub.com. In general, the blue states that expanded the most under Obamacare will see the biggest reversals. That’s because many red states did not expand Medicaid programs. On the other hand, people who were unable to get covered through a private employer will also see reversals, and that’s a different matrix.
WalletHub said the top five states that will see “the highest growth in uninsured population by 2019” would be Massachusetts, West Virginia, Kentucky, New Hampshire and Oregon. The top five states that will see the lowest growth of uninsured will be Alaska, South Carolina, Texas, Oklahoma and Mississippi. Again, a clear red-blue split.
WalletHub’s analysts said the top five states facing “the most potential jobs lost to repeal of tax credits and Medicaid expansion in 2019” were Washington, D.C., North Dakota, Ohio, Oregon and Pennsylvania. The least-hit states in 2019 were Arizona, Hawaii, Mississippi, Washington and Virginia. Looking further ahead, it said the top five states with the “highest potential economic impacts” from 2019 to 2023 were Washington, D.C., North Dakota, Oregon, Connecticut and Alaska. The least impacted states were Arizona, Mississippi, Alabama, Utah and Virginia.
This same jobs-related analysis was done in March by the Economic Policy Institute which found slightly different but overlapping results: “Nationally, all-else-equal, the AHCA could slow job growth by 409,000 in 2019, by 1.1 million in 2020, by 1.6 million in 2021, and by 1.8 million in 2022,” it reported. “The 15 states with the largest reductions in job growth, ranked by jobs-reduced expressed as a share of the total employed population in 2015 are: New Mexico, Kentucky, Montana, Oregon, West Virginia, Rhode Island, Louisiana, New Jersey, Arizona, Washington, Colorado, Nevada, Vermont, Michigan, and Ohio.”
The EPI report also spells out why the House bill is not just a war on Obamacare and Medicaid, but also on blue states: “As a general rule, states and congressional districts with large Medicaid spending fare the worst under the AHCA replacement of the ACA [Affordable Care Act or Obamacare], while states with a high share of rich households do better. This is because the Medicaid cuts drag the most on growth, while the only countervailing stimulus provided by the AHCA is tax cuts that disproportionately boost the incomes for the richest households.”
The Senate Republicans are not just playing politics with one-sixth of the nation’s economy and messing with the lives and livelihoods of millions of Americans. The health care gutting and tax cut policies they are assembling are a direct attack on blue states, which they are seeking to take down to the level of care provided in red-run states that have rejected Obamacare’s prevention-oriented policies, its individual subsidies and its expansion of Medicaid.
If the Washington insiders who know how legislative games are played are correct, McConnell is on track to ram though a bill with no hearings, no public committee markup sessions and only 20 hours of debate—split between the GOP and Democrats. If that sounds like a mockery of democracy, it is. Just as what they might impose on blue states makes a mockery of their health care systems and safety nets.