It’s Baaaaacccckkkk (Sort Of, Maybe)

It is impossible to overstate the Republican commitment to ripping health care from millions, while taking a chainsaw to our medical system.

Rand Paul has just announced that he will vote “Yes” on the Trumpcare motion to proceed as long as he is given a clean vote on his amendment, which would simply repeal the ACA (which, given the CBO evaluation of a similar proposal, would lead to something on the order of 17 million without health care next year, and 32 million Americans left in the cold by 2026).

That’s still not enough to get Trumpcare to the floor if the other declared “Noes” hold out, but each senator McConnell can peel away significantly increases the pressure on those who remain opposed.  And certainly, Paul’s cave reminds us that counting on any Republican to maintain a party-base-unpopular position as a matter of principle is a mug’s game.

This won’t be over until the GOP loses its majority in one house or the other.

Image: Workshop of Lucas Cranach the Elder, Massacre of the Innocents, c. 1515



ACHA review

Here are a few lowlights of the AHCA Congressional Budget Office score. I’ll try to keep this non-technical.

  • Medicaid is still getting changed from an entitlement that is responsive to changing needs to a block grant
  • 23 million people will lose coverage compared to current law projections
  • The MacArthur/Upton waivers are expected to destroy the individual markets that cover 15% of the country
  • Most of the premium decreases are due to older and sicker people being priced out of the market
    • Real easy to have low premiums when you don’t cover anyone who is likely to need services
  • Pre-existing condition protection is effectively destroyed by splitting the risk pool.

Relevant tweets below the fold:
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Medicaid in the President’s budget request

The Department of Health and Human Services accidentally leaked their own budget this evening. Bob Herman at Axios saved a copy. The biggest aspect of the budget is it laid out another $600 billion dollars in cuts to Medicaid and CHIP over ten years in addition to the $820 billion in Medicaid cuts in the AHCA.

Between these two documents Medicaid would lose 47% of its federal funding over a decade.

Loren Adler at Brookings thinks the cuts would be to tie the AHCA block grants to no more than inflation rate growth without regard to population or case mixture. As the Baby Boomers retire, more of them will require nursing home care that is currently paid for by Medicaid but there would be no federal money.

This is a budget wishlist that pits old people versus kids, the disabled against the pregnant and state budgets against upper income tax cuts in the federal budget.

Call Congress and give them an earful.



Call and visit Congress today

The vote for the AHCA in the House is scheduled for sometime around 1:00pm today.

Call your Congressional office today.

If you are in the DC Area there is a protest at the Hill at noon time.

If you are out and about, see if you can visit your Congressional district office to let them know that a vote for the AHCA will result in their names added to an Arya Starkesque mantra.



Time to call Congress

The AHCA has more lives than a serial killer in a horror movie franchise.

The House Freedom Caucus has an agreement to make the bill worse by allowing states to completely opt out of guarantee issue and essential health benefits.

Steven Dennis of Bloomberg has a good fast analysis of the changes:

Most of the House Freedom Caucus is most likely on board with this bill. That reduces the firm no’s that are not in the HFC down to about 20. The No’s from March need to hear from you again. The unknowns and the shaky yeses need to hear from you.

They also need to be reminded of the following:

There is a minimal blocking coalition of Republican representatives who sit in seats that voted for them and Hillary Clinton. Time to remind them that they can’t survive an electorate that is nine points more Democratic in 2018 than it was in 2016. They know that, but let’s remind them.

So time to call Congress again.

I am convinced that any Republican only health care bill will either pass by 3 votes or fail by at least 15 votes.



Third time’s a harm

The Huffington Post has the outline of yet another Republican healthcare deal:

he deal, brokered between House Freedom Caucus chairman Mark Meadows (R-N.C.) and Tuesday Group co-chairman Tom MacArthur (R-N.J.), would allow states to get waivers eliminating the so-called community rating provision ― the rule that prohibits insurers from charging higher premiums to people with pre-existing conditions. In order to obtain the waiver, states would have to participate in a federal high-risk pool or establish their own, and satisfy some other conditions.

In exchange for that conservative concession, the amendment would reinstate the Essential Health Benefits that were already taken out of the bill ― though, again, states could waive those provisions as well if they were able to show that doing so would lower premiums, increase the number of people insured, or “advance another benefit to the public interest in the state.”

What does this mean?
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Super Ugly Waiver (It’s back)

The AHCA is not yet dead. It was just resting for a bit before joining the choir invisible.

The New York Times reports that the White House and the House Freedom Caucus (the hard right flank of the House GOP) have been talking and thinking they have the contours of a deal.

The terms, described by Representative Mark Meadows, Republican of North Carolina and the head of the Freedom Caucus, are something like this: States would have the option to jettison two major parts of the Affordable Care Act’s insurance regulations. They could decide to opt out of provisions that require insurers to cover a standard, minimum package of benefits, known as the essential health benefits. And they could decide to do away with a rule that requires insurance companies to charge the same price to everyone who is the same age, a provision called community rating…..

In simple terms, a carrier can’t deny a hemophiliac coverage but they can charge an actuarial fair premium of $90,000 per year. A carrier can’t deny a young woman who either is or intends to become pregnant. They just don’t have to cover the prenatal or labor and delivery costs.

It is effectively a slightly modified option 3 of Cassidy-Collins where states can return to the 2009 status quo if they so actively elect to do so. If we combine a single state choosing this route and sell across state lines, it would lead the entire country’s individual market back to 2009.

I may be reading too much into the conditional language but to me this is a SUPER (ugly) WAIVER provision. It modifies Section 1332 guard rails to basically meaninglessness. States could then choose to do whatever the hell that they want without concern for coverage requirements. Currently Section 1332 and other waivers in health policy have an equality clause where the states’ preferred options must be at least as good for beneficiaries. This rule would render that null. And I don’t think many/any states would actually take the Feds up on this option as the localized consequences are too immediate and real but if the goal was to design a bill that could get 12% support instead of 17% support, this would be it.

Update 1 This sounds about right to me:

I have no idea how the Tuesday Group stays on board. They were a sufficient blocking coalition under AHCA V1 once the flood gates were starting to open up. The politics of health reform are nasty in the best bills and this is a devolution of a very bad bill. The marginal members of a majority sitting in opposite party or break even districts are the first ones to get hit in a wave.