• Daniel Ethan Finneran

Hungry For Healthcare

June 2017

For some time now, Americans have hungered for a decent healthcare bill. President and Madame Clinton couldn’t get it into the books two decades ago. Their vision was universal, but their result was untenable. Bush’s prospects were no better. His design was humbler, more targeted, and more incremental. Best remembered is he, though, for covering prescription drugs and not changing things much for the better. Obama, the most ambitious of the three, seems only to have come nearest to success—howsoever that might be defined. He shared in a universal vision—like that of the Clintons before him—but his was fraught from the start. The linchpin was cross-subsidization, which looked to many as if it were a shakedown. The young, salubrious part of society would be forced to pay for the care of their elders. Ignoring or protesting would mean a punitive tax.

Taken as a whole, if these four have proven nothing else, they’ve shown that healthcare is a beast. Regardless of who’s at the helm, Republican or Democrat, it continues to be an intractable political sticking point. It’s a cumbersome issue and one that reliably yields frustrating and unpalatable results.

Now, it’s President Trump’s turn to give it a go. His administration and the Republican-dominated Congress is taking its stab at a healthcare bill. Predictably, though, it is not going over well. History’s tendency for repeating itself seldom fails, in the same way that healthcare legislation seldom succeeds.

The Senate has attempted to hurry through its chamber a bill first proposed in the House of Representatives. The original House bill, dubbed the “American Healthcare Act”, or AHCA, was promising, but ultimately doomed. Upon further analysis by the Congressional Budget office, or CBO, the bill, if implemented, would have increased America’s uninsured to 23 million people. The public’s response to this was swift, and its elected officials took note. The CBO’s report dampened any wish for a hasty bill to be made into law.

So, the Senate was passed the baton. All of the Senate’s Democrats, and even a surprising number of its Conservatives, thought the House bill lacking. To improve upon its faults, Republicans scrapped much of its framework and patched together their own. In 142 pages, they presented a bill called the “Better Care Reconciliation Act”, or—you guessed it—the BCRA. In its name is the process whereby they hope to see the bill pass. Republicans want to go through reconciliation, which would require the proposed bill to be two of two things: deficit neutral and agreed upon by a simple majority.

It looks increasingly less probable, however, that they’ll get that chance. As it is, the bill is limping toward an imminent defeat. Liberals are corralling in a unified attack against it. They’ve denounced it wholesale. As they see it, and perhaps not without justification, the bill is as callous as it is cursory. If implemented, preliminary data suggests it will increased the uninsured by many millions. The cold-hard truth is that this bill would contract Medicaid spending while giving high-earning individuals payroll and investment income tax breaks. This is much to the contrary of Obamacare, which redistributed wealth by taxing these same high earners (and the healthcare industry at-large) to pay for the care of penurious Medicaid recipients. As such, Medicaid would be changed fundamentally. Currently, over 74 million Americans rely on Medicaid as their primary form of insurance. These many millions make up a large and diverse swath of people, most of whom share in being either indigent, young, chronically afflicted, or a wretched combination of all three. As it is, in its present form, the federal government funds Medicaid by sending to each state a “blank check”. The state then doles out the welfare as it sees fit. Under the GOP plan, however, Medicaid would change from a “blank check” to a “per capita”, or per person, funding system, wherein states would receive capped block grants to supply the state’s welfare enrollees.

This system, again, proposed by the Senate, has been decried as being callous, but it is admittedly less so than the House’s. Unlike in the House bill, more federal dollars will make their way to the states. These allotments will increase until 2021, at which time the Medicaid “expansion” (a concept detested in Republican circles) would begin to contract. The timeframe might seem suspicious, and that’s because it is. When 2021 comes around, which would be a year after then next presidential election, Republicans may not control the Executive or Legislative Branches. If this turns out to be the case, the Democratic ideal of expansive Medicaid would be no worse for the wear. The exact point at which welfare would be set to contract, they could be ones best positioned to stop it.

In addition to changes in funding, Senate Republicans are also flirting with the idea of work requirements. This concept (which is lauded on the Right and loathed on the Left) would require able-bodied Medicaid beneficiaries to work for their keep. Excepting pregnant women, children, elderly individuals, and people with incapacitating disabilities, Medicaid recipients would partake in public sector jobs—most of which would be menial and physical. A few states have trialed the program to varying degrees of success. If implemented judiciously and well, it could be a valuable thing. And while Democrats oppose it, the idea does have teeth.

Work requirements are a point of contention, but they are not the point of contention. No, that award belongs to the issue of pre-existing conditions. Democrats want them to be covered unconditionally. Conservatives, if they’re to remain true to their creed, do not. The House bill wanted to dispense with Obama’s call for insurers to cover pre-existing conditions. This, they thought, would be a practical return to the status quo ante, before the ACA was imposed. Republican Senators, though, recognized that once a benefit is given (like guaranteed coverage of pre-existing conditions) it is not so easily rescinded. In an attempt to split the baby, Republican Senators have proposed a system in which states would be given the option to waive benefit requirements. The option to opt out or remain in would be theirs.

On the whole, that’s the Senate bill. One can see how Democrats think it’s callous. But I also mentioned its being cursory. While one can dispute its callousness, the same can’t be said for how hastily it’s been put before a vote. Senators Orrin Hatch (R-UT) and Mike Lee (R-UT), both conservative stalwarts, were basically ignorant of the bill’s details. Neither was given the chance to examine the bill as it evolved behind closed doors. They, in particular, should’ve had a role in its construction, but instead, they hadn’t an inkling of what was happening. Such a monumental piece of legislation—a sweeping healthcare bill—demands the meeting of many, many minds. Unfortunately, they were left on the outside looking in, and now find a bill foisted into their laps.

Obamacare is imperfect. Republicans like Hatch and Lee think it irreparably so. Slowly, Democrats are coming to the realization that it must change if it’s to survive. They think that there’s potential in its improvement, but that it needn’t be eviscerated—yet. The problem is that they, the Democrats, didn’t want to acknowledge this on the Republicans’ terms. But as the minority party, they must. Still, though, the BCRA isn’t as far a stretch from the ACA as it could’ve been. The effects of Medicaid reform and pre-existing conditions notwithstanding, much of the BCRA retains Obamacare’s content. And, as pointed out, states will have the option to keep the Obamacare structure, should they choose to do so.

You can’t please everyone in life. No truer are these words when you’re in the thicket of healthcare reform. It’s the dense under-belly of the beast of public opinion. Except maybe for taxes, healthcare is the most personally-relevant political issue for society as a whole. This means that, more than any other issue, it lends itself to sentimentality and irrationality. Obscured by these emotions of the heart and not the mind is the fact that this could be a decent bill. It could be just the right mix of Obama’s bureaucracy and Trump’s liberalism; a dash of the old and a garnish the new. An insatiate society awaits.

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