POV: Senate Republicans’ Health Care Reform Bill Will Hurt Millions

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For seven years, Republicans have promised to “repeal and replace” the Affordable Care Act (aka Obamacare), and they may finally be able to do so. We should all worry that they might succeed. They have proposed a cruel and heartless bill that will hurt millions of Americans.

But that may be beside the point for them. Based on the bill’s content, it appears that its main purpose is to provide a massive tax cut for the wealthiest Americans. Reducing health care spending is simply the way chosen to pay for it. Although, incredibly, they call their bill the Better Care Reconciliation Act, it is not primarily a health care bill at all, but a tax bill.

One clue that this is the case is that although their anti-ACA rhetoric has been constant for years, it has never been clear what problems they are trying to solve. They use nonspecific words like “disaster” and avoid detail. If they were serious about health policy, they could propose ways to improve it. Instead, however, they want to repeal a law that although imperfect, has done lots of good for many individuals and families. Since the ACA’s accomplishments are well known—check out the websites of the Commonwealth Fund or the Kaiser Family Foundation—I won’t take my limited space here to repeat them. Suffice it to say that as a result of the ACA, millions more Americans have health insurance, health care costs have risen at the lowest rates in decades, and the law constrains firms that offer the employer-provided insurance that most of us have in ways that prevent them from victimizing us—especially those with preexisting conditions—as they did for years before the ACA was passed.

The largest spending cuts will be to Medicaid, the federal-state program passed in 1965. Not only did the ACA allow states to expand their Medicaid programs to include people with incomes up to 138 percent of poverty, it said the federal government would pay the full cost of that expansion for three years and then at least 90 percent of it after that. In other words, it provided free money to those states that wanted to, first, help their residents, and second, expand their economies (and tax revenues) at the same time. Even with those inducements, however, governors and legislatures in 20 states decided to reject the offer. The reason: political ideology. They don’t believe either that people should have access to needed medical care unless they can pay for it or that government has a role in helping them.

The Republicans’ Senate bill not only would sharply reduce federal support for Medicaid expansion, but also would dramatically change the way the underlying program is funded. From its inception, Medicaid has reimbursed the states for the money they spend on medical care for eligible residents. That allows doctors and patients to make the critical care decisions. Instead, the new bill would apply arbitrary dollar amounts to the care a person could receive. The effect of this change would be to limit the care that eligible Medicaid beneficiaries can receive—even if it is not enough to treat their conditions. In addition, they would forbid using Medicaid money to pay for services provided by Planned Parenthood, even though in some places it is the only source of preventive and other care for women.

One of the few specific complaints Republicans have had about the ACA is that it requires almost all Americans to buy health insurance and requires larger companies to provide affordable coverage to employees—and in both cases imposes penalties on those who fail to comply. Those provisions were included in the ACA so that the risk pools would be as large and diverse as possible and the insurer would have enough money to pay for services used by covered individuals. The Republicans’ Senate bill eliminates the penalties, even though we know from Massachusetts’ Romneycare experience in the ’90s that without penalties, many young, healthy people will decide not to buy coverage. If that happens, the risk pools will not be large enough to pay for the care of those who are covered. In addition, because costs will be higher, those who do buy coverage may not be able to afford insurance that meets their needs.

The fact is, however, everyone needs insurance. While the probability that young people will use care is low, it is not zero. Everyone has some chance of needing services, even expensive ones. Examples: breaking a leg playing ball, being hit by a drunk driver who runs a red light, even developing cancer. Insurance frees them from worry that they can’t afford the care they need.

The bottom line is this: if the Republicans’ Senate bill becomes law, millions of Americans will lose their coverage altogether. For those who get to keep it, it is likely to be more expensive and cover less.

But as I said at the outset, the main reason this bill even exists is to cut the cost of publicly funded medical care in order to reduce taxes on the wealthy. That sounds outrageous to me, but it will happen unless three Republican senators with a conscience or who expect a close reelection race next year vote against it. As of this writing, six have said they oppose the bill, forcing GOP leaders to announce on June 27 that they would delay a vote on the bill until after the Senate’s weeklong July 4 recess. It’s hard to believe, but it might fail because several senators plan to vote against it because it is too generous.

Stephen M. Davidson is a Questrom School of Business professor of markets, public policy, and law and the author of Passage and Implementation of the Affordable Care Act and A New Era in U.S. Health Care: Critical Next Steps Under the Affordable Care Act. He can be reached at sdavidso@bu.edu.

“POV” is an opinion page that provides timely commentaries from students, faculty, and staff on a variety of issues: on-campus, local, state, national, or international. Anyone interested in submitting a piece, which should be about 700 words long, should contact Rich Barlow at barlowr@bu.edu. BU Today reserves the right to reject or edit submissions. The views expressed are solely those of the author and are not intended to represent the views of Boston University.