In a sickening display of malevolence overcoming incompetence, House Republicans voted Thursday to take the first significant step in passing a bill which will have catastrophic effects on health insurance for tens of millions of Americans. The exact impact of the bill, the American Health Care Act, is unknown, because Speaker Ryan and his fellow Republican legislators voted on the bill after only one hour of debate, and long before the Congressional Budget Office could estimate how new amendments would alter their previous report on the AHCA, which the nonpartisan office said would leave 24 million Americans without health insurance by 2026. After the previous attempt at passing AHCA was stymied by both the House Freedom Caucus and other Republicans, these amendments placated both groups by making the bill significantly worse for those affected.
The foundation of the AHCA remains the same from the last go around: roughly a trillion dollars in tax cuts for the wealthy, roughly $900 billion in cuts to Medicaid, and the replacement of the ACA individual mandate with a 30% penalty on insurance premiums for those who get insurance after a gap in coverage. That’s the bill that failed back in March. The new amendments are, respectively, an attempt to gut the ACA’s basic consumer protections and coverage regulations (to win over the Freedom Caucus) and an attempt to hide that gutting with laughably inadequate additional funding for individuals (as a figleaf of political cover for comparatively more moderate House Republicans). The end result would be to roll the national clock back to 2009, to an era when pre-existing conditions led to bankruptcy, denial, and death for many Americans.
The MacArthur amendment allows states to apply for waivers against two key provisions of the ACA, those protecting individuals with pre-existing conditions and those requiring all health care plans to cover a list of essential health benefits.
Under the version of AHCA which just passed the House, state waivers would allow insurance companies to charge people with pre-existing conditions anything they wanted. This is functionally not different from the pre-ACA health care market, where those with pre-existing conditions were denied coverage or priced out of the healthcare market. Pre-existing conditions, it should be noted, is a term that includes anything from birth defects and childhood illnesses to cancer and HIV, from minor infections to long-term work-related injuries. The situation is particularly brutal for women, as experiences like pregnancy or sexual assault are also considered pre-existing conditions–the latter case meaning victims of rape and sexual assault will have to choose between reporting a crime and affording health care. Individuals could see annual premium increases of tens of thousands of dollars, placing health care out of reach for many.
Assuming consumers can afford whatever the insurance company decides to charge them for, say, having once had a yeast infection or being born prematurely, will they at least have coverage according to their needs? That’s where the other state waiver comes in. Under the MacArthur amendment, state waivers would allow insurance companies to ignore ACA requirements that all insurance plans cover a list of essential health benefits, including hospitalization, prescription drugs, emergency services, laboratory services, and pediatric care. As a result, companies in states that receive a waiver will likely move to offer so-called catastrophic plans, which offer very little coverage; these plans are attractive for young, healthy people but end up discouraging preventative care and leaving individuals who do end up with health problems without the proper insurance.
Two aspects to the overall situation make these provisions real problems. First, just as many predominately Republican or Republican-led states have refused to take the ACA Medicaid expansion (which, it’s worth repeating, will be gutted under AHCA), it’s likely that many of the same states will apply for both of these waivers (and have those waivers granted by the Trump administration).
America could become a nation of two tiers of health insurance: blue states with coverage requirements and pre-existing condition protections, and red states with zero protections for consumers. Imagine moving from California to Texas only to find that your condition is either no longer covered or is too expensive for you to afford insurance.
Second, Trump and other Republicans have been strongly in favor of allowing companies to sell health insurance across state lines.
Don't worry, getting rid of state lines, which will promote competition, will be in phase 2 & 3 of healthcare rollout. @foxandfriends
— Donald J. Trump (@realDonaldTrump) March 7, 2017
When combined with state waivers from coverage and premium regulations, this could cause a national race to the bottom where whichever state offers the least regulations exports its low standards across the country, just as Delaware currently does for credit card companies. This would render Representative Pittenger (R-NC)’s advice Tuesday to simply move to a state with an insurance market you prefer as useless as it is callous.
Why pass an unpopular bill that throws the healthcare market into chaos and will inevitably result in the deaths and financial ruin of thousands of Americans if it becomes law? House Republicans are simply hoping to get the issue off their plate and into the Senate, where media and activist attention will fall on Mitch McConnell and the handful of Republican Senators who might vote against the Senate version of AHCA (no doubt being hastily scribbled on cocktail napkins right now). Whether the bill will get through the Senate, and in what form, is as yet unknown, but the successful House vote makes its ultimate passage significantly more likely.
For their part, Democrats hope to use this vote against every House member who helped pass the bill in an attempt to take back control of the chamber in 2018. In a statement Wednesday, House Minority Leader Nancy Pelosi promised that “House Republicans are going to tattoo this moral monstrosity to their foreheads, and the American people will hold them accountable.”
In sum: 217 powerful people voted Thursday to kill thousands of Americans, bankrupt many more, and strip health care from tens of millions. They did so with essentially no debate and no firm understanding of the details of the legislation they were passing. And they seem to have done so in order to claim an accomplishment, any accomplishment, after months of embarrassing inaction and unfulfilled promises. That night, they traveled to the White House to celebrate their achievement with cold beer in the Rose Garden.