Last week Republicans in the House passed the American Health Care Act and tossed it over to the Senate, which reacted as though someone had deposited a pile of rotting garbage on its doorstep. Republican senators have said that since the House’s bill is so dreadful, they will be starting from scratch to write their own bill.
As they proceed, there are some very important questions they need to be asked, ranging from the broadly philosophical to the extremely specific. Let’s take a look at some of them:
According to the Congressional Budget Office, a previous version of the House bill would have led to 24 million Americans losing their coverage; the bill that passed last week could be even worse. How many people will lose coverage under the Senate’s bill?
Eventually, the CBO will score whatever bill the Senate produces, so we’ll know the answer to this question. But Republicans need to answer for it and explain what happens to those who lose coverage.
If you revoke the Affordable Care Act’s expansion of Medicaid, millions of poor people are going to lose their coverage. The tax credits in the House bill will come nowhere near to covering what private insurance costs, for those people or for those who got subsidies under the ACA. Under your bill, what happens to a family that can’t afford private insurance with what you’re offering them? Are they just out of luck?
The people who benefited from the Medicaid expansion are the most vulnerable, because they don’t make enough money to afford private insurance. There’s also a large population of people receiving subsidies that are much more generous than the tax credits Republicans have suggested as a substitute. So what will their fate be?
Do you know how many people in your state are at risk of losing their coverage?
This should be an important number for any senator, and fortunately, people have done the calculations. For instance, in Ohio, if the AHCA became law, 654,000 people could lose their coverage. It might be interesting to see how each senator reacts when confronted with the number in his or her state who are at risk.
The fundamental principle of insurance is that we should spread risk as widely as possible. Do you believe that principle is mistaken?
The approach the House took was to separate out the potentially most expensive patients — those with preexisting conditions — and concentrate them together. That will lower costs for the young and healthy but raise them for people who are older and who have been sick in the past. If Republicans think that’s a good idea, they should say so plainly.
Can you guarantee that people with preexisting conditions will be able to afford coverage?
Right now, those with preexisting conditions can get insurance like everyone else, no questions asked. Republicans would instead shunt them into high-risk pools, which in the past have failed at the state level because they have been underfunded, have charged unaffordable premiums and often wouldn’t cover people’s preexisting conditions until they had been in the pool for a long period, such as six months.
The House bill would end the ACA’s protections for those with preexisting conditions, allowing states to get waivers to exempt them from the requirement. As Sen. Susan Collins (R-Maine) said, “It’s true that under the House bill that a state that gets a waiver would still have to provide coverage to people with preexisting conditions. But that coverage might well be unaffordable. And if the coverage is unaffordable, that doesn’t do any good for a child who has juvenile diabetes and is going [to] have that her entire life.” So how would the Senate solve that problem?
The House bill cuts $880 billion from Medicaid, which now serves approximately 70 million Americans. How much will your bill cut from Medicaid?
Republicans have been madly spinning on this issue, trying to argue that hundreds of billions in cuts aren’t really cuts at all. Senators need to say exactly how much they plan to cut.
Republicans often say they want states to have “flexibility” in administering Medicaid. Can you promise that your bill won’t allow states to cut Medicaid benefits or kick people off the program?
When Republicans talk about giving states flexibility, they’re never specific about what kind of flexibility they’re after. Instead, they toss around meaningless words and phrases such as “innovation” and “focusing on the patient.” Speaking to ABC News on Sunday, House Speaker Paul Ryan (R-Wis.) used the word “customize” six times to describe some unspecified thing that states will be able to do to their Medicaid programs once they’re released from federal rules. But senators need to be asked to name specific things that they would like states to be able to do that current Medicaid rules forbid them from doing. Because the real answer is: Cut benefits and kick people off the program.
The House’s plan offered a spectacular tax cut for the wealthy — those in the top one-tenth of one percent of incomes would get tax cuts averaging more than $200,000. By how much does your bill cut taxes for the wealthy?
One pithy summation of the Republican health-care effort is that they want to cut health benefits for millions of people with modest incomes so that they can give a huge tax cut to the rich. Is the Senate bill going to do the same thing?
The House bill would once again allow insurers to impose “lifetime limits” on coverage so that if you have a serious accident or illness, you could lose your coverage. Will the Senate bill do the same thing?
The answer to this ought to be pretty straightforward.
Will your bill forbid women on Medicaid from getting health services at Planned Parenthood clinics?
That’s what “defunding” Planned Parenthood means, and it was part of the House bill: Medicaid patients who now go to Planned Parenthood for services such as gynecological exams and cancer screening will be forced to find someplace else to get care. Is this going to be part of the Senate’s bill, too?
Do you believe it’s better for someone to get insurance from a government program than to be uninsured?
You wouldn’t think that would be a controversial position to take, but many state Republicans plainly believe just the opposite, which is why they refused the ACA’s Medicaid expansion. They would have been able to insure their poor citizens without paying anything — numerous independent analyses found that despite the modest contribution states would have to make to cover that population (the federal government pays 90 percent of the cost), doing so would save states money in the end. But 19 Republican-run states said No. So senators should be asked whether they’d rather see a family go uninsured rather than be on Medicaid or another government program. If not, they should describe how that principle is embodied in their legislation.
Do you believe that health care is a right? Should it be treated like education, where rich people might be able to buy a fancier version, but the government guarantees that everyone gets it no matter what? Or is it just one more commodity such as cars or cellphones, and if you can’t afford it then that’s too bad?
This is a fundamental question of values, and every senator should say plainly whether his or her answer is Yes or No. Then we’ll have a clear idea of what they’re going to do when we’re not looking.