Republican Attempts to Destroy the ACA
Trumpcare bills died in the Senate, but the ACA is far from safe.
Trump has severely undermined and destabilized insurance markets by threatening to end the cost-sharing subsidies that make Obamacare work. Republicans in Congress did their part too, by including a provision in the tax bill eliminating the ACA's individual mandate (which imposed fees on people who chose to remain uninsured, and used that revenue to lower insurance rates for everybody else.) And Republican-led statehouses are seeking federal approval to institute work requirements for Medicaid recipients in the state; Kentucky's plan was approved in January, 2018, and nine more states are seeking to implement similar plans.
In addition, Trump effectively ended the ACA’s contraceptive coverage mandate by issuing new rules allowing any employer, public or private, to deny birth control coverage by claiming a religious or moral objection. The employer need not get permission from or even notify the federal government before ending coverage. Simply put, unless state law or regulations dictate otherwise, women’s contraceptive coverage is now in the complete discretion of their employers.
Make no mistake: the GOP's ultimate goal is to rip health insurance away from millions of Americans, harm women's health, and limit reproductive freedom.
To understand the details of each GOP bill (the AHCA, the full BCRA, the "skinny repeal," and Graham-Cassidy) keep reading . . .
First, the House AHCA:
The American Health Care Act (AHCA) is the House version of the ACA-repeal bill. It passed the House on May 4, 2017.
The AHCA contains several provisions that will damage women’s health care and take away reproductive freedom. These provisions appeared in almost identical versions in the subsequent Senate BCRA bills, and again in the latest Graham-Cassidy bill. Read thoroughly and carefully, because this is the GOP's plan for the future of women's health care in Trump's America:
- The AHCA allows states to drop the requirement that insurance plans provide “essential health benefits” including preventive care, maternity care, and birth control.
The AHCA replaces federal insurance subsidies with tax credits, and prevents tax credits from being applied to insurance plans that cover abortion. That’s right: you can’t get the tax credit if you buy a plan that includes coverage for abortion—whether you ever actually used that coverage or not. So if you want insurance that covers the medical procedures you need to have control over your body, you will have to buy that coverage separately. And there’s no guarantee that separate coverage will even be available, let alone affordable, since insurance companies will have zero incentive to provide abortion coverage.
The AHCA prevents Planned Parenthood clinics from receiving any Medicaid reimbursement for the health care services they provide for one year. We’re not talking about abortion here, since the long-standing Hyde Amendment already prevents Medicaid reimbursement for abortion. We’re talking about all health care services: birth control, STD screening and treatment, routine gynecological care, etc.
For low-income women who rely on Medicaid to pay for health care, this will be devastating, as they will likely have no alternative clinics to use. The Republicans say that other “federally qualified health centers” can handle the patients that Planned Parenthood now serves, but that is just not true! In an independent analysis of the AHCA, the Congressional Budget Office noted that “the people most likely to experience reduced access to care would probably reside in areas without other health care clinics or medical practitioners who serve low-income populations.”
Moreover, the Congressional Budget Office estimated that defunding Planned Parenthood for one year would increase the number of births in the Medicaid program by several thousand, increasing direct spending for Medicaid by $21 million in 2017 and by $77 million over the 2017-2026 period. So not only does the AHCA trample over reproductive freedom, it also increases Medicaid costs (while slashing the budget to pay those costs, as you'll read below).
The AHCA allows insurers to charge higher premiums to people with pre-existing conditions by letting states seek waivers to the rule restricting price differences based on medical background. Insurance companies in the states that opt to do this will then be free to increase premiums to the sick. Even for healthy women, this means premiums will increase as insurers consider things like pregnancy and prior C-sections as pre-existing conditions. Still more horrifying, insurance companies can return to their pre-Obamacare practices of counting past treatment for sexual assaults and domestic violence as pre-existing conditions.
The AHCA cuts $880 billion over ten years from Medicaid and ends the expansion of Medicaid, which was the central component of Obamacare that allowed people with income below 133% of the poverty level to get health insurance. The 31 states that already expanded Medicaid will get federal funding to continue it only until 2020, after which funding will be reduced. States that did not expand Medicaid are now forbidden to do so. The structure of Medicaid funding will also change: states will be given a fixed amount of money per enrollee (known as a per-capita cap), or, if they choose, a lump sum per year regardless of how many participants are in the program (known as a block grant). Both of these funding structures will encourage states to reduce eligibility, curtail benefits or cut provider payments. Moreover, states will also be allowed to impose work requirements for able-bodied adults.
Next, the Senate BCRA (full and skinny versions):
The Better Care Reconciliation Act (BCRA) is the Senate version of an ACA repeal bill. The full BCRA was virtually identical to the AHCA in the provisions that harmed women's health. That full bill failed in round one of Senate voting in early July.
In round two, the Senate tried to pass a so-called "skinny repeal," which--among other things--eliminated the coverage mandates, eliminated funding for Planned Parenthood for one year, and allowed states to let insurance plans eliminate coverage for "essential health benefits." This skinny repeal failed in the full Senate on July 28, 2017, thanks to steadfast opposition by Democrats, as well as crucial no-votes by GOP Senators Susan Collins, Lisa Murkowski, and John McCain.
Although they called it skinny, this version was no less deadly than any other GOP plan. Here's why:
- First, the coverage mandates--which require individuals and employers of 50+ full-time employees to pay a penalty if they do not have/provide health insurance--are what help pay for the other elements of the ACA. So eliminating those funds would have been a crucial blow to the viability of the ACA.
- Second, even the "skinny repeal" was projected to take health insurance away from 16 million Americans per the latest CBO report.
- Third, the Planned Parenthood defunding is exactly what the House proposed in its original AHCA bill: denying all Medicaid reimbursement to Planned Parenthood for the health care services they provide.
- Fourth, as Chuck Schumer said, the skinny repeal was simply "a ruse to get full repeal." If the Senate GOP was able to pass anything, that bill would have gone back to the House, where ultra-right GOP Representatives were ready to amend it to bring it in line with their original AHCA bill.
On September 13, 2017, four white male GOP senators (Lindsey Graham, Bill Cassidy, Dean Heller and Ron Johnson) released what they call the Graham-Cassidy bill. This bill is simply Trumpcare by another name and contains all of the provisions of the AHCA and BCRA that were devastating to women's health:
- Eliminates Medicaid reimbursement to Planned Parenthood for one year
- Allows states to change what qualifies as an "essential health benefit" so that insurers might no longer be required to provide cost-free coverage for maternity care, birth control, and preventive care like breast and cervical screenings
- Prevents individuals from receiving tax credits for insurance plans that cover abortion (with exceptions for abortions to save a woman's life, or for pregnancies from rape or incest)
- Allows states to impose work requirements for Medicaid
- Allows states to permit insurance companies to consider pre-existing conditions when setting coverage costs
- Prevents any future expansion of Medicaid, while also reducing federal reimbursement to states that have already expanded Medicaid and--shockingly--ends all federal contributions to Medicaid in 2027
- Changes the structure of Medicaid funding to block grants, in which the federal government gives states a fixed amount of money regardless of the number of people who need services, thereby encouraging reduced eligibility and curtailed benefits for the neediest Americans