Trumpcare: the president delivers a poison pill to his electorate

In their minds, these privileged few were Rocky entering the ring, William Wallace leading the charge at Stirling Bridge. Republican Congressman Jason Chaffetz rode in on a scooter, fresh from foot surgery covered by his subsidised government health insurance, to vote for a bill that will make the same operation unthinkably expensive for tens of millions of Americans. If it becomes law, thousands more will die each year because they cannot afford to see a doctor.

In the Rose Garden, President Donald Trump touted the AHCA as “a really incredible health care plan” and promised “we’re going to get this finished.” Then, for six weeks, as the media focused on the investigation into Russian interference in the presidential election, a group of thirteen senators met to draft the Senate’s version of the bill in total secrecy. On Thursday, it was released for the briefest possible period of discussion. By this Friday, it could be law.

The renamed Better Care Reconciliation Act (BCRA) will deprive at least twenty million people of health insurance. It drastically cuts Medicaid, which provides low cost health care for those least able to afford it, reduces subsidies to the working poor and lower middle-class, allows insurers to charge old people five times as much as the young, and lets states opt out of a list of ‘essential health benefits’ so insurers can sell policies that don’t cover maternity or outpatient services, mental health treatment or prescription drugs. Premiums and out of pocket expenses will continue to rise, but people making $200,000 a year will get a tax cut.

Obamacare took a year to draft. Democrats tried to work with Republicans on a bi-partisan bill for months, and when that failed, debated the legislation on the Senate floor for five weeks. Then Minority Leader Mitch McConnell complained that they were “ramming through” the law. Now he is doing everything in his power to shield the Republican alternative from scrutiny. The hypocrisy is stunning, the cynicism absolute.

Polls show only 29% of voters have a favourable opinion of the Republican bill, making it even more disliked than the bank bailout of 2008. The American Medical Association, American Nurses Association, American Academy of Family Physicians, American Association of Retired Persons and American Hospital Association have all spoken out against it.

Even insurers are opposed, despite the many sweeteners to the industry it contains, because the cuts to Medicaid, a reliable source of income, are so deep. “To me, this is not a reform,” Michael J. Dowling, the chief executive of Northwell Health, said. “This is just a debacle.”

A survey of 1,100 doctors found that 66% had a “negative impression” of the AHCA. The Sunday Herald interviewed five medical professionals from five states, all registered Republicans. They were unanimously critical of Obamacare, but even more dismayed by its proposed replacement.

“I consider myself a fiscal conservative, and fiscally this is a horrible thing, because it’s going to keep increasing the cost curve. The only thing conservative about it is it will lower the tax rate for those in the top percent,” said Roger LaBonte, president of the West Tennessee chapter of Physicians for a National Health Plan.

“It’s already a disaster for the Republican Party. If they pass something, it’s a total disaster. If they don’t, it makes them look like a bunch of clowns,” said Jack Bernard, former director of health planning for the state of Georgia.

Republicans have been predicting Obamacare’s collapse from the beginning, and since taking power have helped it along the way, introducing instability in the insurance market by threatening to remove federal subsidies. Insurers, citing losses, have been pulling out of the state exchanges. Next year, more than 30,000 people in Missouri and Ohio will qualify for a government subsidy but have nowhere to spend it, as not one company is selling insurance.

In Arizona, Obamacare cut the number of uninsured in half. More than 600,000 benefited from the expansion of Medicaid to cover those earning up to 133% of the federal poverty level - around $32,000 for a family of four. People buying insurance on the state exchange have been less fortunate, as Blue Cross Blue Shield now enjoys an effective monopoly, and can charge what it likes.

Daniel Derksen, Director of the Arizona Centre for Rural Health, said the proposed cuts to Medicaid, more than $800 billion over a decade, would be disastrous for the state. “This goes beyond repealing Obamacare: it’s really dismantling an essential title of the Social Security Act.” Medicaid will be capped, tied to inflation and guaranteed to buy a little less each year, but not until 2021, after the next presidential election, to soften the political blow.

When Derksen was asked why Republicans are so determined to pass such an unpopular bill, knowing it will hit older people in rural areas - Trump voters - particularly hard. “Well, if you’re going to do a ginormous tax cut, you’ve got to do a ‘pay-for,” he said, “and one of the largest federal expenditures is our Medicaid and Medicare programmes.”

This is the key to understanding the bill. By cutting subsidies and Medicaid, it lowers the projected deficit by roughly $1.2 trillion over a decade. This creates space for a permanent ‘revenue-neutral’ tax cut that can be passed in the Senate with a simple majority. The 3.8% tax cut on investment income in the bill, back-dated to the start of this year, is just an appetiser.

From 2010-2016, Obamacare reduced the number of uninsured from 48.6 million to 28.6 million and eliminated many of the insurance industry’s most egregious abuses, but as a market-based solution, devised in a conservative think tank and pioneered by Republican Governor Mitt Romney in Massachusetts, it stopped far short of meaningful reform.

According to the Organisation for Economic Co-operation and Development, the USA spends $9,500 per capita on health care each year, compared with $5,300 in Germany, $4,000 in the UK and $2,500 in Israel, but has the lowest life expectancy and highest infant mortality rate in the developed world. That is a sick and broken system.

“About 48,000 Americans die every year because of lack of health care. The biggest cause of bankruptcy in this country is people who can’t pay their medical bills,” said Rade Pejic, a chest surgeon from New Orleans. He told how the wife of a doctor friend recently had an outpatient hip operation and received a bill for $97,000, and that his cousin’s appendectomy cost $32,000. These are not extreme cases.

The number of people with no health insurance at all - close to fifty million by 2026 if the GOP bill passes - is the tip of the iceberg. Tens of millions more, on all but the most expensive plans, are under-insured, with high deductibles (the first few thousand dollars the policy holder has to pay before the insurance kicks in) and yawning gaps in their coverage.

A Kaiser Family Foundation survey found that one in five people with health insurance received medical bills last year that they struggled to pay. Of these, 63% reported using up most of their savings, 38% said they ran up credit card debt and 37% asked friends for money. Under the GOP plan, the poor, the sick, the elderly - everyone but the richest - will pay more for meaner and less reliable insurance.

“We’re facing higher and higher deductibles, narrowing networks, because the insurance companies run the show. They dictate health care that doctors practice,” said Alan Kenwood, an emergency room doctor at a hospital in Morris County, New Jersey. “There is a fear of standing up for what’s right because of the power of the lobbies, the insurance and pharmaceutical industries, and they have such deep infiltration into both parties.”

Last year, the chief executive of insurer Centene, Michael Neidorff, earned $22 million. Humana’s Bruce Broussard got $19.7 million. Alan Miller, CEO of hospital chain Universal Health Services, received $51.3 million in salary and stock options.

Most of the senators who drafted the BCRA have received substantial campaign contributions from the health care industry. From 2011-2016, Kindred Healthcare gave McConnell $104,650. Sanford Health gave Senator John Thune $40,246. Blue Cross Blue Shield paid Senator Lamar Alexander $36,250. The list goes on.

The question now is whether Republicans can agree on a bill that will pass the Senate, and then the House, with its fanatically tax-averse Freedom Caucus. McConnell can only afford two “no” votes, and at the last count, seven senators were wavering: three because the BCRA is too much like Obamacare and four worried that the Medicaid cuts will harm their constituents and hamper their re-election chances.

Bernard predicted dire political consequences: “I think if the Republican Party is dumb enough to pass this, they will lose the presidency and a whole series of senatorial seats. When people who are working-class start to see their brothers and sisters and children getting booted off health insurance, you’re gonna hear screaming.”

“It’s quite possible that the level of anger is going to be so great that it’s going to push reform and there’s going to be a strong reaction against the Republican party for pushing the legislation,” said Kenwood.

For a taste of irony amid all this, we should maybe hark back to January 2015, five months before Trump announced his presidential campaign, when he told an anecdote on David Letterman’s show about a friend who spent four days in a Scottish hospital: “He was really in trouble, and they released him and he said, ‘Where do I pay?’ And they said, ‘There’s no charge.’ Not only that, he said it was like great doctors, great care.”

For now, though, as congressional Republicans prepare to put a bill on Trump’s desk that will make health care more expensive, more stressful and less secure for the vast majority of Americans, the President’s talk of “insurance for everyone” is just one more empty promise.

Our man in America: check my health bills

My own run-ins with for-profit health care include the time I was asked for cash up front to remove four stitches, the $2,800 bill for unspecified ‘hospital services’ that arrived after the birth of our son (for which our insurance had already paid the hospital $15,000) and the several thousand dollars worth of vaccinations not covered by our policy. Last month my wife went for an annual check-up and received a bill for $2,080 from the laboratory for a few routine blood tests, despite having comprehensive insurance provided by her employer.