click to enlarge Senate Majority Leader Mitch McConnell (R-KY)

Senate Majority Leader Mitch McConnell (R-KY)

On the Senate's no-good, very bad health care bill 

Informed dissent

There is one thing about which you can be sure: If the Senate health care bill passes, people will die. A lot of people.

That sounds hyperbolic. But it's true. In 2009, before Obamacare, a study in the American Journal of Public Health linked a lack of health insurance to 45,000 deaths per year. (This paper covered one of those deaths, that of South Orlandoan Charlene Dill, in depth.) Last year, the Urban Institute estimated that between 27,000 and nearly 36,000 people a year would die prematurely if the Affordable Care Act were repealed. Last week, the Center for American Progress, working with a Harvard professor, projected that, should the Senate bill pass, some 27,000 people would die prematurely in 2026.

These studies were based on statistical modeling rather than hard body counts, so their findings are debatable. But the undergirding logic is simple: People without health insurance don't see doctors as often, and they tend not to get the same frequency or quality of care. Hence, they die sooner.

For the sake of argument, assume these numbers are wild exaggerations. Assume the real number is one-fifth what the Center for American Progress came up with. That's still 5,400 people a year – more than 1 and a half times the number who perished during 9/11, and we've been fighting a war for 16 years now over that. This tragedy we're planning by design.

The Affordable Care Act, for all of its sundry imperfections, reduced the rate of uninsured Americans to an all-time low, from 16.6 percent of the non-elderly population in 2013 to 10 percent in 2016, according to the Kaiser Family Foundation. It did so through generous subsidies for middle- and lower-income people and the expansion of Medicaid, paid for by taxes on the wealthy. It also made the health insurance plans people purchased worth something. Insurers could no longer offer cheap plans with insanely high deductibles that covered almost nothing.

While about 29 million people remain uninsured, this is progress. The Senate's health care bill would undo all of it.

As I write this, there's no Congressional Budget Office score of the so-called Better Care Reconciliation Act of 2017, so we don't know how many people will lose insurance. The bill was written in secret by a dozen male Republicans and unveiled to the public on Thursday; a CBO analysis should come early next week, with the Senate voting a few days later.

There will also be none of the endless hearings and debates and town halls and amendments that characterized the passage of the ACA in 2009 and 2010. No, this was done in darkness, because the men who crafted it know you're not going to like what you see.

In broad terms, the BCRA keeps the basic structure of its House companion, the American Health Care Act, which the CBO projected would cost 23 million people their insurance coverage. It eviscerates Medicaid, a program that helps the poor and disabled, and reduces the tax credits that help people afford coverage. This is done to offset $1 trillion in tax cuts, 40 percent of which will go to the top 1 percent of earners. (Warren Buffet estimates he'll save about $680,000 on his tax bill.)

That's $400 billion to the 1 percent, while tens of millions of people lose their health care. How is that moral?

And it gets worse. In 2019, the Senate bill eliminates what are called cost-sharing reductions, which help poor people with out-of-pocket medical expenses. As NBC News noted, for those who earn 150 percent of the federal poverty line – $36,500 for a family of four – those CSRs reduced the average deductible from $3,609 to $255. 

Gone, too, will be the guarantee of what are called essential health benefits – things like maternity and mental health care that the ACA forced all insurers to cover. This will allow insurers to move healthy people into lower-cost plans that cover less, which in turn will make it more difficult for sicker people to find plans they can afford. So while the ACA's pre-existing condition mandate will still exist on paper, it will be watered down in practice. 

It also lowers the income threshold for health care tax credits, from 400 percent of the federal poverty line to 350 percent. For those who still receive the subsidies, they'll pay for less, as the subsidy amount is pegged to a less-comprehensive, higher-deductible plan. In other words, you'll get crappier health care, and you'll pay more for it.

Again, this is all being done not to improve health care, but to finance a $1 trillion tax cut for the rich. Again, I ask, how is this moral?

It's not. And they know that. Which is why it was crafted in the shadows, and why it will be muscled through with only a modicum of debate. The Republicans know it doesn't stand up to scrutiny. They know it is utterly devoid of empathy. They know that it's mean, to borrow a word from President Trump. They know it will hurt people. They know people will die.

They just don't care.

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