Despite immense pressure this week from GOP leadership and the White House—which desperately wanted their Obamacare repeal bill to pass within President Trump’s first 100 days in office—moderate Republicans held out. Trumpcare 3.0 met the same fate as its previous iterations, and everyone promised to try again later.
Rep. Charlie Dent (R-PA), the co-chair of the centrist Tuesday Group, says he and his colleagues have so many concerns about the core policies in the plan that Republicans should consider starting over. “We need to change the paradigm,” he told reporters Friday. “I think the bill has got too many problems, and they need to rework it from the center out.” Specifically, Dent and other holdouts cite the bill’s deep cuts to Medicaid, rate hikes for older Americans, and insufficient protections for people with pre-existing conditions.
But GOP leaders are not heeding his advice, and are instead vowing to keep trying to get the same Obamacare repeal bill to President Trump’s desk in the weeks to come. These are the not-yet-addressed concerns that will come back to haunt them.
Sorry, sick people
The 16-odd moderate Republicans openly opposing the latest iteration of the GOP health care bill, and the dozens who remain undecided, repeatedly cited the bill’s potential impact on patients with pre-existing conditions. Under the newly-adopted amendment to the bill, states could apply for waivers to Obamacare’s community ratings—essentially, the cost protections for the sick and the elderly. If the waiver is granted, insurance companies could drastically hike the premiums of people with serious medical conditions—in some cases by tens of thousands of dollars.
“Many Republicans have made statements saying they want to protect people with pre-existing conditions. But this amendment calls into question that protection, that guarantee,” Dent said Friday.
After years of railing against the Affordable Care Act, even conservative GOP leaders have said that the law’s protections for pre-existing conditions are popular and should be preserved. Still, the bill has over the past few weeks made life more precarious for the millions of people in this category. If someone with a pre-existing condition experiences a lapse in coverage—for example, due to losing a job—there appears to be no limit to what insurers can charge them.
A machete to Medicaid
The GOP’s original repeal bill would have caused 24 million people to lose their health insurance, according to the non-partisan Congressional Budget Office (CBO)—an even more devastating coverage loss than simply repealing Obamacare. Much of this rollback would come from the bill’s long-term gutting of Medicaid, including the freeze in 2020 of states that have expanded Medicaid over the last several years, and a subsequent $800 billion reduction in funding for the program.
The CBO calculated that “roughly 9 million fewer people would enroll in Medicaid in 2020; that figure would rise to 14 million in 2026,” as a result of funding cuts.
“The Medicaid piece doesn’t provide a soft enough landing for states like mine that have expanded it,” Dent said Friday. “And I was told we can’t do anything about that.”
Republicans pushed for a vote on the amended bill this week knowing that the CBO would not have time to release an updated analysis, meaning they would have voted without knowing how much the bill would cost or how many people could lose coverage.
This was a major issue for Rep. Mark Amodei (R-NV), who like Dent hails from a Medicaid expansion state and is not supporting the bill. “I want to see how the plan lays out, step by step, the terms of funding and eligibility [of Medicaid],” he said. “I want the information before I vote.”
Coverage that barely covers
The amendment to the bill unveiled earlier this week would also allow states to seek waivers to Obamacare’s rule that insurers cover 10 essential health benefits—such as prescription drugs, emergency room visits, maternity care, and mental health services. In short, insurance companies will be able to charge people far more money for far skimpier plans.
Supporters of the bill, including Rep. Chris Collins (R-NY), have argued unsuccessfully with their more skeptical colleagues that this wouldn’t affect the populations of more progressive states, which will not attempt to get such a waiver.
“I’ve been talking to my fellow members who have some problems with the essential health benefits [provision],” Collins told reporters. “In New York, there’s nothing to be afraid of for our constituents. We’ve always had guaranteed issue [for people with pre-existing conditions]. We’ve always had community rating. We have 42 essential health benefits. Nothing will change in New York.”
Collins did not mention, however, that the bill would hit New Yorkers in a different way. Because all New York health insurance plans must—under state law—cover medically necessary abortions, they would be ineligible for any tax credits if the GOP bill passes.
Remember the Maine!
As negotiations over the health care bill have dragged on, Republicans have rolled out one amendment after another, promising that each one was the magic ticket that would bring the party together. One of the biggest tweaks, unveiled just before Congress left D.C. for a two-week recess, concerns the national implementation of the kind of high-risk insurance pools that existed before Obamacare—pools that priced many people out of the market entirely.
Republicans have said this plan is based on a success story in Maine, which has had an invisible risk-sharing program since 2011. But not only was Maine’s program not the success story lawmakers claim—many individuals and small businesses saw their premiums skyrocket and insurance companies watered down their plans—the GOP’s national plan allocates just a fraction of the funding needed to sustain such a system.
The bill allocates $100 billion dollars over 9 years to subsidize high-risk pools for those with the most severe health care needs, and what would happen after that funding expires is not addressed. Even conservative economists estimate that a national system for covering people with pre-existing conditions with high-risk pools could require as much as $20 billion per year in federal subsidies, just to cover about 4 million people on the individual market.
The AARP estimates that if such a system is created, and not properly funded, people in those high-risk pool could have to pay more than $25,000 year in premiums alone.
Fleecing grandma and grandpa
No one would be hit harder by the GOP’s proposed health care overhaul than older Americans, particularly those too old to work but too young to qualify for Medicare.
The CBO analysis of the original bill found that the premiums for a 64-year-old would jump by 20-25 percent by 2026 compared to leaving the current law in place. The office also predicted the number of uninsured would disproportionately rise among older people with lower incomes if the bill passed.
The amendments since that bill was pulled due to lack of support among hard-right Republicans have further eroded protections for older Americans.
Now, states can apply for waivers to Obamacare’s age bands, which limit how much insurance companies can charge older patients compared to younger ones. Under Obamacare, that ratio is 3 to 1. Under the GOP bill, companies can charge older patients five times as much. At the same time, the tax credits allocated for older Americans would be significantly stingier than those currently offered under the ACA.