The American Health Care Act and the Better Care Reconciliation Act of 2017 both purport to repeal and replace the Affordable Care Act or Obamacare with something better. The proposed plans get rid of many of the features that made the Affordable Care Act what it was. During the campaign Trump promised, “No one will lose coverage. There will be insurance for everybody. Healthcare will be a ‘lot less expensive’ for everyone — the government, consumers, providers.”[i] Trump also promised that there would be no cuts to Medicaid. The two proposed bills promoted by Congress fail to live up to any of those promises. In the state of Alabama, which Trump won by nearly a 2:1 margin, 62.1% to 34.4%, he ran on those promises on health care lying to every person who voted for him, and 180,000 Alabamians chance losing their health insurance as a consequence.[ii]
The CBO estimates that the American Health Care Act of 2017 (referred to as the House bill going forward) will cut 834 billion dollars from Medicaid by cutting the enhanced Medicaid expansion and by diminishing the per capita-based payments to each state. It also purports to reduce or eliminate subsidies on the individual market by 276 billion dollars. With the elimination of the individual mandate, some people will stop buying health insurance since there is no penalty for not doing so, but its largest impact will be in the amount of people on Medicaid; less people on Medicaid means a lot more uninsured. With the elimination of the protection for people with pre-existing conditions, those policies will vastly increase in price meaning that people who have pre-existing conditions will now pay, depending on their conditions, perhaps tens or hundreds of times the cost of health insurance for a healthy young person. Even if all states that opted out of pre-existing coverage protections adopted high-risk pools that gathered all people with pre-existing conditions into their own marketplace and those states provided funding to keep premiums lower it is hard to imagine that they could raise enough funds to support all people with pre-existing conditions in perpetuity. Over the course of the next decade, the CBO predicts that 23 million more people will lose healthcare coverage than have it today and that by 2026, 51 million people will be uninsured compared to 28 million under current law of the Affordable Care Act (referred to as the ACA going forward).[iii]
Similarly, the Better Care Reconciliation Act of 2017 (referred to as the Senate healthcare bill going forward) cuts Medicaid less than the House bill by only 772 billion compared to 834 billion over the next decade but reduces subsidies on the individual market by a more significant 408 billion. By 2026, 22 million more people will be without insurance than under current law and an estimate population of 49 million people will be without insurance in 2026 compared with 28 million under the ACA.[iv]
It is time to address why this matters to Alabama. According to the Robert Wood Johnson Foundation study, published on June 28, 2017, the House bill would cause 138,000 to lose insurance in Alabama compared to current law, and would lose one billion, forty-five million in federal funding or 19.6%.[v] The Senate bill would cause 164,000 to lose insurance in Alabama compared to current law and would cost Alabama one billion, one hundred and thirty-eight million in federal funding compared to current law or 21.4%.[vi] According to the Alabama Hospital Association, “Rural hospitals are the lifeblood of much of Alabama. They provide emergency medical care to those in need and preventative health care that sustains rural communities. They employ thousands of hardworking Alabamians and drive local economies through their payrolls, purchases, and infrastructure investments…In Alabama, 50 hospitals meet the federal criteria to be considered ‘rural.’ These hospitals treat more than 110,000 patients annually.”[vii] Rural hospitals, which received a boom in their reimbursements with a greater number of insured patients under the ACA, will now receive a hit that could lead to closings of those hospitals that serve as the lifeblood of their communities.[viii] Also teaching hospitals such as UAB will be impacted by these proposed laws because UAB definitely benefited from the decreased instance of uninsured patients as a result of the ACA.[ix] All this uncompensated care that will result from the repeal of the ACA will just increase the burden on hospitals causing some to outright go out of business. In Alabama, 68% of nursing home patients rely on Medicaid to pay for their long-term care. According to Alabama Nursing Home Association spokesman, John Matson, “Alabama’s elderly population is growing. The U.S. Census reports there were 660,000 Alabamians age 65 and over in 2010. By 2025, the population could reach 955,000, Matson says. ‘On the other side of that, in 2010 there were 76,000 Alabamians 85 plus,’ Matson says. ‘By 2025, that number is expected to grow to 110,000. So we can see that there is coming a silver tsunami in the next 10 years in Alabama.’”[x] Medicaid cuts will disproportionately affect this vulnerable population.
The Senate and House bills also want to eliminate the regulations of the ACA which required coverage of what the ACA called “essential health benefits,” this will allow people to buy so-called “catastrophic plans;” these were plans that had lower premiums and higher deductibles in which enrollees payed for all their medical care out-of-pocket until they hit their deductible which was often their out-of-pocket maximum. These plans were okay if you were young and healthy and could prevent you from going bankrupt but they were a gamble; if you were young and healthy you were gambling that you wouldn’t get sick so all you would ever pay was the lower premium and you would hopefully never get sick and have to pay those thousands of dollars of the deductible. But those essential health benefits that the ACA adopted vastly increased what health insurance covered and it included mental healthcare, substance abuse treatment and rehabilitation, maternity care, preventative care, imaging such as X-Rays, MRIS and CT scans, Labs, Physical Therapy, Primary and Specialist Care, Prescription Drugs, etc. Prior to the ACA, insurance companies could choose to cover any, all, or in many cases almost none of these basic healthcare benefits. And to get coverage to cover all of them would have been more expensive than the average person could afford in the individual marketplace. The way the ACA changed this was to make all plans cover these essential benefits but to offer different tiers of plans (bronze, silver, gold, and platinum) which altered the balance between premium and deductible. Those with pre-existing mental healthcare or substance abuse issues will be hard-hit by the new Senate or House bill. According to Dr. Scott Harris, assistant state health officer for the Alabama Department of Public Health, “‘I really can’t think of a bigger issue that’s facing the health of Alabamians than the current opioid epidemic.’ Between 2013 and 2014, the number of drug overdose deaths in Alabama increased by about 20 percent, which was the second-largest increase in the country that year. Prescription drugs account for about half the drug overdose deaths in the state, Harris said.”[xi] According to “Linda Rosenberg, president and CEO of the National Council for Behavioral Health, said any bill is poor policy if it threatens coverage for those with mental health issues, or doesn’t treat mental illness as seriously as physical illness. ‘Mental illness is an illness like any other,’ Rosenberg said. ‘People recover and they can live full and productive lives with effective treatment. We just have to be sure that treatment is still available in every community, just like we do for cancer and heart disease.’”[xii] Repealing the ACA now in the midst of the opioid epidemic and just when mental health had begun to be addressed as an issue in our healthcare system would threaten to throw the system into chaos.
What the Republicans often claim about the Senate and House bills is that those bills are about repealing and replacing the ACA in a more fiscally responsible way. They claim the ACA is failing, that its premiums keep going up and that its deductibles are too high. While the ACA is not perfect; i.e., the premiums are going up and the deductibles are too high, but those aspects could be addressed through reform of the ACA. The uncertainty in the marketplace where the current administration refuses to support the status quo, and even threatens to stop paying the subsidies built into the ACA itself which would cripple it, is also a main driver of rising prices.[xiii] The idea that the GOP wants to tackle the American Healthcare system in a more fiscally responsible way by lowering the deficit needs to be taken with a grain of salt if you look at what the Senate and House bills actually do. While there are provisions in both bills that drastically cut Medicaid by about 800 billion dollars and that minimize the subsidies by hundreds of billions of dollars the federal government pays to individuals to buy health insurance, they also have provisions within each bill that add to the national debt by repealing taxes imposed by the ACA in order to pay for the subsidies and new Medicaid spending. Those taxes were levied on insurance executives, medical device manufacturers, and on the top echelon of tax payers. In the House bill, the tax repeal will net those stakeholders 664 billion dollars.[xiv] The Senate Bill will net those stakeholders 541 billion dollars.[xv] If the GOP was really concerned about the deficit and the National Debt they could have cut Medicaid and kept in the taxes; combined over a decade it would have cut the national debt by one trillion three hundred and thirteen billion in the Senate bill and one trillion four hundred and ninety-eight billion in the House bill. This makes the GOP’s motive of cutting taxes for their wealthy donors so transparent because getting the tax cuts into the healthcare reform bills is only step one of a plan to reform the tax code and cut the tax rates in a later bill.[xvi] In Alabama, according to the U.S. Census, the median household income is only $43,623, and the per capita income is merely $24,091; 18.5% are considered in poverty. For this proposed tax cut, perhaps only a handful of families (probably no more than 100) in the entire state would benefit but between 138,000 and 164,000 will lose their health insurance.[xvii] How many Alabamians will live shortened lives or outright die so that the super-rich can have a tax cut? It would be like the Sheriff of Nottingham going around the peasant villages, hooking all the poor up to the torture machine from “The Princess Bride” which saps years off their lives and then turning those years into gold coins to give to the nobles at court.
If either of these bills pass, all the millions people that lose their health insurance will once again rely on the emergency rooms of our hospitals as their primary care. The Emergency Medical Treatment and Labor Act (EMTLA) enacted in 1986 makes sure that anyone coming into the emergency room has to be stabilized and treated regardless of their ability to pay or their insurance status. This uncompensated care was a primary driver of healthcare costs prior to the ACA and will be a primary driver of healthcare costs under either GOP plan as millions of people lose the insurance they had under the ACA. Prior to the ACA, the EMTLA also encouraged uninsured people if they were of very low income to go to the emergency room for non-urgent care thus clogging up the emergency room when real emergencies presented themselves. EMTLA was never a be-all or end-all solution to the American healthcare system because it was not universal care as some pundits claimed; it hardly covered any medical care beyond emergency services; emergency services would include a woman going into labor, a person undergoing a heart attack, someone suffering from a sudden trauma like a gunshot wound, and if you were acutely obstructed by massively advanced colon cancer you could get surgery to remove the blockage. However, since EMTLA fails to include primary or preventative care then you could not get the statin medication to prevent you from developing that heart attack in the first place or a colonoscopy to detect the colon cancer early or chemotherapy to treat it. The overall health of American citizens will go down because people under the ACA who had insurance for the first time used it to get preventative care or to check out and get treatment for issues that may have plagued them for years; under the GOP plans people will put off getting treatment until a medical problem is an emergency and then it is often too late to prevent a disease from spreading or an injury from crippling the patient. If the GOP bills pass, we will back to a system where millions of people use the EMTLA as their primary means of medical care and that will drive up medical costs for everyone far faster than the rate of medical costs and health insurance rises today.[xviii]
In conclusion, the Senate and House bills that want to repeal and replace the ACA may repeal the ACA, but will hardly replace it with something that is even comparable in quality. The Senate and House bills get rid of the hated individual mandate, but that feature lowered the cost of insurance by guaranteeing a certain percentage of healthy young people would buy insurance that prior to the ACA would not have done so, thus lowering premiums for everyone. The Senate and House bills will likely destroy the Medicaid expansion in those states that expanded it and will also drastically reduces federal spending on Medicaid going forward which will cause states to drop coverage or drop people from the rolls. This will affect vulnerable populations such as the elderly and the mentally ill. This will also increase the number of uninsured driving up insurance rates for everyone else. The Senate and House bills also get rid of much of the subsidies that the federal government paid to individuals to make health insurance affordable which will increase the number of uninsured thus raising insurance rates on the rest of us. The Senate and House bills also allow states to opt out of the “essential health benefits” which allows insurance companies to sell plans that just like before the ACA cover any, all, or almost none of the medical conditions people need health insurance for in the first place. The Senate and House bills also allow states to opt out of the provisions of the ACA which prevented insurance companies from charging people with pre-existing conditions more and the provisions that limited out-of-pocket spending and prevented lifetime limits on coverage; these provisions made insurance affordable for millions of Americans who happened to be born or happened to develop a crippling disease or syndrome.[xix] It will not stem the rising healthcare costs because it will once again drive millions more uninsured Americans to the emergency room for uncompensated care who had health insurance under Obamacare. The only thing the Republican Senate and House bills do effectively is they cut taxes on special interests and the wealthy, their core constituency. It will benefit a handful of wealthy Alabamians at the cost of throwing over 100,000 of their fellows off their health insurance.
When I wrote this in July 2017, the Senate was contemplating passing several versions of the bill above. In the interim, the Senate failed to pass any version when Senators John McCain, Susan Collins, and Lisa Murkowski joined their Democratic colleagues in voting down the final form of the bill, known as “skinny repeal.” In the weeks since that historic vote, Senate Majority leader Mitch McConnell has attempted to move on despite President Trump making threats to Republican Senators and Congressmen that came out against the bill. Now a bipartisan group of Senators is attempting to shore up Obamacare to assure the stability of the individual market. They face off against a group of conservative Republicans, with the support of the Trump administration, who want to repeal Obamacare. Both groups face a deadline that expires at the end of September. The bipartisan shoring up of Obamacare would secure the one-sixth of the economy that healthcare represents and allow Congress to finally move onto different issues such as the debate over tax reform. The conservative repeal plan may finally allow those Republicans to say that they fulfilled their campaign promise seven years in the making, though it will kick off millions of people from their insurance, including hundreds of thousands in Alabama.[xx]
[i] Henry C. Jackson, “6 promises Trump has made about health care,” March 13, 2017, found at: http://www.politico.com/story/2017/03/trump-obamacare-promises-236021 [accessed on July 12, 2017].
[ii] Amy Yurkanin, “Obamacare enrollment in Alabama dips after Trump’s inauguration,” February 4, 2017, found at: http://www.al.com/news/index.ssf/2017/02/obamacare_enrollment_in_alabam.html [accessed on July 12, 2017];.
[v] Linda J. Blumberg, et al. “State-by-State Coverage and Government Spending Implications of the American Health Care Act: Timely Analysis of Immediate Health Policy Issues,” Robert Wood Johnson Foundation, June 2017, found at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2017/rwjf438332/subassets/rwjf438332_1 [accessed on July 12, 2017].
[vi] Linda J. Blumberg, et al. “State-by-State Coverage and Government Spending Implications of the Better Care Reconciliation Act: Timely Analysis of Immediate Health Policy Issues,” Robert Wood Johnson Foundation, June 2017, found at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2017/rwjf438332 [accessed on July 12, 2017].
[vii] Alabama Hospital Association, “Rural Hospitals at a Crossroads,” found at: http://www.alaha.org/wp-content/uploads/2015/04/Rural-Hospital-Booklet.pdf [accessed on July 12, 2017].
[viii] Howard Koplowitz, “Alabama’s rural hospitals would close under Trumpcare: Democrats,” found at: http://www.al.com/news/index.ssf/2017/06/alabamas_rural_hospitals_would.html [accessed on July 12, 2017].
[ix] Andrew Kreighbaum, “How Higher Ed Would Feel Medicaid Cuts,”Inside Higher Ed, July 6, 2017, found at: https://www.insidehighered.com/news/2017/07/06/senate-health-care-bill-bad-news-teaching-hospitals-and-universities-groups-say [accessed on July 12, 2017].
[x] Gail Allyn Short, “Medicaid Looks Home,” Business Alabama (December 2015), found at: http://www.businessalabama.com/Business-Alabama/December-2015/Medicaid-Looks-Home/ [accessed on July 12, 2017].
[xi] Amy Yurkanin, “Education critical for Alabama doctors on the front lines of ‘opioid epidemic,’” Real-Time News from AL.com, November 18, 2016, found at: http://www.al.com/news/index.ssf/2016/11/education_critical_for_alabama.html [accessed on July 12, 2017].
[xii] Lindsay Holmes, “Trumpcare Will Be Catastrophic For People With Mental Health Issues,” Huffpost.com, May 04, 2017, found at: http://www.huffingtonpost.com/entry/trumpcare-mental-health_us_590b5576e4b0104c734c94c1 [accessed on July 12, 2017]
[xiii] Anna Maria Barry-Jester, “The Obamacare Marketplaces Aren’t In A Death Spiral,” found at: https://fivethirtyeight.com/features/the-obamacare-marketplaces-arent-in-a-death-spiral/ [accessed on July 12, 2017].
[xvi] Robert Reich, “Trumpcare isn’t about health. It’s a tax cut for the 1%,” The Guardian, June 276, 2017, found at: https://www.theguardian.com/commentisfree/2017/jun/26/trumpcare-health-tax-cut-1-percent [accessed on July 12, 2017].
[xviii] Angela Marx, “The GOP’s Big Lie about Healthcare and Hospital ERs – EMTALA,” March 28, 2012, found at: https://www.dailykos.com/stories/2012/3/28/1078468/-The-GOP-s-Big-Lie-about-Healthcare-and-the-EMTALA-law [accessed on July 12, 2017]; Sarah M. Miller, “The ACA Helps Correct Incentives for Patients to Use the Health Care System Inefficiently,” August 30, 2013, found at: http://www.rwjf.org/en/culture-of-health/2013/08/the_aca_helps_correc.html [accessed on July 12, 2017]; American College of Emergency Physicians, “The Impact of Unreimbursed Care on the Emergency Physician,” 2002, found at: https://www.acep.org/Clinical—Practice-Management/The-Impact-of-Unreimbursed-Care-on-the-Emergency-Physician/ [accessed on July 12, 2017]; Aaron Carroll, “Why emergency rooms don’t close the health care gap,” found at: http://www.cnn.com/2012/05/07/opinion/carroll-emergency-rooms/index.html [accessed on July 12, 2017].
[xix] Matthew Fiedler, “Like the AHCA, the Senate’s health care bill could weaken ACA protections against catastrophic costs,” Brookings Institute, June 23, 2017, found at: https://www.brookings.edu/blog/up-front/2017/06/23/like-the-ahca-the-senates-health-care-bill-could-weaken-aca-protections-against-catastrophic-costs/ [accessed on July 12, 2017].
[xx] Jennifer Haberkorn, Adam Cancryn and Rachael Bade, “Bid to shore up Obamacare faces time crunch, conservative countereffort,” September 6, 2017, http://www.politico.com/story/2017/09/06/obamacare-republicans-repeal-242416 [accessed on September 6, 2017].