By Merrill Goozner | September
26, 2017
Don't kid yourself. We haven't heard the last of repealing and
replacing Obamacare.
The GOP's latest attempt to undermine the law failed because three Republicans, the bare minimum, had enough sense to oppose legislation that would create chaos throughout one-sixth of the U.S. economy. The Graham-Cassidy bill would have given every state just two years to completely revamp their Medicaid programs and individual insurance markets with an estimated $1 trillion less money over the next decade.
According to the best available estimates (the usually reliable Congressional Budget Office could only give directional estimates for what 50 state legislatures might do), tens of millions of Americans would have lost insurance coverage. Hundreds of thousands of healthcare workers would have lost their jobs. There would have been a massive shift in resources from states that expanded Medicaid under the Affordable Care Act to states that had not.
In states with GOP-controlled statehouses (Republicans now have 33 governors and control 32 legislatures), insurance companies would have become largely deregulated. People with pre-existing conditions in many of those states would get slapped with soaring rates. Bare bones coverage with huge out-of-pocket expenses would become the norm in many regions of the country.
Despite the loud protests of organizations representing every major healthcare constituency—hospitals, doctors, insurance companies, patient advocacy groups—every GOP senator save three were willing to sign onto the bill. There can be no doubt that had it passed the Senate, it would have sailed through the House and given President Donald Trump something he desperately needs—a bill, any bill, that he can claim as a success for his first year in office.
As soon as Senate Majority Leader Mitch McConnell admitted defeat for a second time, the bill's architects vowed to attach it to the budget bill that must be approved to avoid a government shutdown. Conservative hardliners took to the airwaves to call on the Trump administration to cut off its month-to-month support for the cost-sharing subsidies that allow insurers to lower out-of-pocket expenses for the poorest Americans who buy plans on the exchanges.
HHS under Secretary Tom Price, meanwhile, continues to do its part by sabotaging the upcoming enrollment season. It has slashed funding for navigatorsthat help people sign up, cut weekend hours for online enrollment and drastically cut advertising and marketing.
Given the fundamentally conservative nature of Obamacare—it relied on private insurers and Medicaid to expand coverage, not single-payer or other more radical measures—one has to ask why the GOP remains fixated on destroying something that has worked fairly well. The uninsured rate is in single digits; and overall healthcare spending, rising at its slowest pace since the 1990s, enabled the government to spend nearly a half trillion dollars less than originally expected on Medicare, Medicaid and subsidies for the uninsured.
The easy answer is that it is all about the increasingly nasty infighting on the Republican right. You can't scream "repeal and replace" for seven years and then fail to deliver. It makes every Republican incumbent vulnerable to extremist challengers in next year's primaries.
Sen. Bob Corker of Tennessee read the tea leaves and announced his retirement. A few hours later, Sen. Luther Strange of Alabama, who was appointed to fill Attorney General Jeff Sessions' seat in the Senate and was backed by Trump, was ousted by ex-judge Roy Moore, a religious fundamentalist and arch-conservative.
But something deeper is at work. In a must-read article in the latest New Yorker, Dr. Atul Gawande returned to his native Athens, Ohio, a college town on the edge of Appalachia, to talk about health reform with local residents. He provocatively began with this question: "Is healthcare a right?"
Many of the people he spoke with had serious healthcare needs. Those with employer-provided health insurance struggled to pay their co-pays and deductibles. They repeatedly denounced people on Medicaid who get health insurance at almost no cost to themselves, saying they "just don't work. They're lazy."
The idea that Medicaid is filled with able-bodied people unwilling to work has become a staple of the current healthcare debate. Yet, before the Medicaid expansion, which by definition applied only to the near poor working at jobs without employer-based coverage, less than 20% of people on Medicaid were able-bodied adults, neither aged or disabled. Many of them cared for children, who make up 60% of people in the program.
No doubt there are shirkers among the able-bodied adults on Medicaid, just as there are shirkers in every workplace that offers employer-based coverage. But that's no reason to deny them access to healthcare—not if we agree that it is a right of every citizen.
Gawande notes near the end of his article that "the ACA postponed reckoning with our generations-old error of yoking healthcare to our jobs—an error that has made it disastrously difficult to discipline costs and insure quality, while severing care from our foundational agreement that, when it comes to the most basic needs and burdens of life and liberty, all lives have equal worth.
"The prospects and costs for healthcare in America still vary wildly, and incomprehensibly, according to your job, your state, your age, your income, your marital status, your gender and your medical history, not to mention your ability to read fine print," he wrote.
As long as that's the case, unscrupulous politicians will be able to exploit the resentments those inequities breed, and pit one group of Americans against another for their own electoral advantage. Graham-Cassidy may be dead, but repeal and replace lives on.
The GOP's latest attempt to undermine the law failed because three Republicans, the bare minimum, had enough sense to oppose legislation that would create chaos throughout one-sixth of the U.S. economy. The Graham-Cassidy bill would have given every state just two years to completely revamp their Medicaid programs and individual insurance markets with an estimated $1 trillion less money over the next decade.
According to the best available estimates (the usually reliable Congressional Budget Office could only give directional estimates for what 50 state legislatures might do), tens of millions of Americans would have lost insurance coverage. Hundreds of thousands of healthcare workers would have lost their jobs. There would have been a massive shift in resources from states that expanded Medicaid under the Affordable Care Act to states that had not.
In states with GOP-controlled statehouses (Republicans now have 33 governors and control 32 legislatures), insurance companies would have become largely deregulated. People with pre-existing conditions in many of those states would get slapped with soaring rates. Bare bones coverage with huge out-of-pocket expenses would become the norm in many regions of the country.
Despite the loud protests of organizations representing every major healthcare constituency—hospitals, doctors, insurance companies, patient advocacy groups—every GOP senator save three were willing to sign onto the bill. There can be no doubt that had it passed the Senate, it would have sailed through the House and given President Donald Trump something he desperately needs—a bill, any bill, that he can claim as a success for his first year in office.
As soon as Senate Majority Leader Mitch McConnell admitted defeat for a second time, the bill's architects vowed to attach it to the budget bill that must be approved to avoid a government shutdown. Conservative hardliners took to the airwaves to call on the Trump administration to cut off its month-to-month support for the cost-sharing subsidies that allow insurers to lower out-of-pocket expenses for the poorest Americans who buy plans on the exchanges.
HHS under Secretary Tom Price, meanwhile, continues to do its part by sabotaging the upcoming enrollment season. It has slashed funding for navigatorsthat help people sign up, cut weekend hours for online enrollment and drastically cut advertising and marketing.
Given the fundamentally conservative nature of Obamacare—it relied on private insurers and Medicaid to expand coverage, not single-payer or other more radical measures—one has to ask why the GOP remains fixated on destroying something that has worked fairly well. The uninsured rate is in single digits; and overall healthcare spending, rising at its slowest pace since the 1990s, enabled the government to spend nearly a half trillion dollars less than originally expected on Medicare, Medicaid and subsidies for the uninsured.
The easy answer is that it is all about the increasingly nasty infighting on the Republican right. You can't scream "repeal and replace" for seven years and then fail to deliver. It makes every Republican incumbent vulnerable to extremist challengers in next year's primaries.
Sen. Bob Corker of Tennessee read the tea leaves and announced his retirement. A few hours later, Sen. Luther Strange of Alabama, who was appointed to fill Attorney General Jeff Sessions' seat in the Senate and was backed by Trump, was ousted by ex-judge Roy Moore, a religious fundamentalist and arch-conservative.
But something deeper is at work. In a must-read article in the latest New Yorker, Dr. Atul Gawande returned to his native Athens, Ohio, a college town on the edge of Appalachia, to talk about health reform with local residents. He provocatively began with this question: "Is healthcare a right?"
Many of the people he spoke with had serious healthcare needs. Those with employer-provided health insurance struggled to pay their co-pays and deductibles. They repeatedly denounced people on Medicaid who get health insurance at almost no cost to themselves, saying they "just don't work. They're lazy."
The idea that Medicaid is filled with able-bodied people unwilling to work has become a staple of the current healthcare debate. Yet, before the Medicaid expansion, which by definition applied only to the near poor working at jobs without employer-based coverage, less than 20% of people on Medicaid were able-bodied adults, neither aged or disabled. Many of them cared for children, who make up 60% of people in the program.
No doubt there are shirkers among the able-bodied adults on Medicaid, just as there are shirkers in every workplace that offers employer-based coverage. But that's no reason to deny them access to healthcare—not if we agree that it is a right of every citizen.
Gawande notes near the end of his article that "the ACA postponed reckoning with our generations-old error of yoking healthcare to our jobs—an error that has made it disastrously difficult to discipline costs and insure quality, while severing care from our foundational agreement that, when it comes to the most basic needs and burdens of life and liberty, all lives have equal worth.
"The prospects and costs for healthcare in America still vary wildly, and incomprehensibly, according to your job, your state, your age, your income, your marital status, your gender and your medical history, not to mention your ability to read fine print," he wrote.
As long as that's the case, unscrupulous politicians will be able to exploit the resentments those inequities breed, and pit one group of Americans against another for their own electoral advantage. Graham-Cassidy may be dead, but repeal and replace lives on.
Merrill Goozner served as Editor of Modern
Healthcare from December 2012 to April 2017. As Editor Emeritus, he continues
to write a weekly column, participate in Modern Healthcare education, events
and awards programs and provide guidance on coverage related to healthcare
transformation issues. Over the course of his four decades in journalism, he
served as a foreign, national and chief economics correspondent for the Chicago
Tribune and professor of journalism at New York University. He is the author of
The $800 Million Pill: The Truth Behind the Cost of New Drugs (University of
California Press, 2004), and has contributed articles to numerous publications.
Goozner earned a master's degree in journalism from Columbia University and a
bachelor's in history from the University of Cincinnati, where he received the
Distinguished Alumni Award in 2008.
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