Affordable Care Act Update: Cassidy-Collins, Rand Paul, and a Whole Lot of Heartlessness

As of January 24th, Republicans are planning to begin hearings on the intial Affordable Care Act replacement plans this week. By now, you’ve probably heard of the closed-door meeting about repealing and replacing the ACA at the Republican retreat in Philadelphia on Thursday. Spoiler alert: they have no real plan to replace the ACA. I know, what a shock. At least, they have no consensus plan that would provide coverage anywhere near as thorough to anywhere near as many people as does the ACA. We need to know what these plans are so we can call upon our representatives to speak out against them. Remember, Republicans can’t replace the ACA without the cooperation of Democrats, so they’re now discussing undermining the law through a combination of executive orders, measures like the budget reconciliation process, and other legislative means that permit them to chip away at the law over time such that it dies a slow and agonizing death. Even orders and legislation that appear to be relatively minor add up, so keep an eye on what Republicans are doing.

Now onto the plans. You may recall that Senator Susan Collins and Senator Bill Cassidy both expressed reservations regarding repealing the ACA without a replacement. Senator Collins specifically signified her dismay with the provision to defund Planned Parenthood (which is a complete and total misnomer, because not only is there no line item in the federal budget for Planned Parenthood, thanks to the Hyde amendment federal dollars don’t pay for abortions anyway). Well, now they have the draft of a so-called replacement plan, though not much of one. In what is perhaps the definition of irony, they dubbed their plan the Patient Freedom Act. Why is this ironic? Patients, in fact, have very little real choice here. As is par for the course with Republican ideology, choice is left to the states, and constituents are left to sink or swim depending upon what their states choose and whether they happen to be among the top income brackets.

So what are the choices that the Cassidy-Collins plan, alias the “Patient Freedom” Act, offer to states? Number one: keep the ACA, but with less funding. Number two: the default State Alternative Plan that deregulates the insurance market and allocates a Health Savings Account (HSA) to each person, again with less funding. Number three: absolutely nothing, but with some pretty-sounding consumer protections in place that will be wildly ineffective in practice.

Cassidy-Collins is extremely complex, in fact more so than the ACA, undermining Republicans’ criticism of the ACA’s complexity. Funny how that happens. For option one, states have to jump through political hoops to keep the ACA. Low- and moderate-income families will experience a healthcare cost increase because states would only receive 95% of the funding that they would have under the ACA as it now stands. There is also no suggestion that funding will be adjusted in accordance with healthcare costs, which are obviously not static over time. Bottom line for option one: in liberal states, people would get to keep a pseudo-ACA that’s more expensive than what we have now. So much for Republicans’ moaning and groaning about how unaffordable healthcare coverage is.

Option two is that in which people would automatically be enrolled. I won’t get too wonky here, but if you want to get in the weeds, give Timothy Jost’s explanation from the Health Affairs Blog a read. Each person gets what’s called a Roth HSA with a set amount of money that bears no relation to income levels. You know what that means — tax breaks for the wealthy, while low- and moderate-income people will have to pay through the nose to receive basic healthcare. Again, option two provides less federal assistance than does the ACA. And since the federal financial support would cover a larger population since it would also go to higher income folks, that leaves less assistance for those who really need it. It also guts consumer protections, so women, senior citizens, and people with preexisting conditions will see higher premiums, and plans can drop or limit essential health benefits like covering maternity care and prescription drugs. I don’t know if you’ve ever seen what a prescription drug costs without health insurance, but I have, and it’s breathtakingly expensive. Meanwhile, people will face higher deductibles. You also have to maintain continuous coverage or you could face penalties. So, for instance, if you have a chronic illness and lose your job that supplies your health insurance, well, sucks for you. Insurance companies can refuse to cover you if you have a preexisting condition and didn’t maintain continuous coverage or charge you an exorbitant sum of money. And even if you don’t have a preexisting condition, insurance companies would be within their rights to take away your coverage and increase costs, among other things. So that ban against insurance companies discriminating against folks with preexisting conditions? It sounds good, but as Shakespeare might say, it’s a lot of sound and fury signifying nothing.

And then there’s option three. This would permit states to choose not to provide healthcare for residents at all, which would mean that they wouldn’t receive any federal funding for healthcare programs. This includes Medicare and Medicaid. If you live in one of these states, sure, you can go into the insurance marketplace and attempt to purchase coverage, but you’re on your own. And it sounds marvelous and all that children can stay on their parents’ plans until age 26 and insurance companies can’t impose lifetime or annual caps on the amount of medical care they cover, but if you can’t afford coverage in the first place — which will be the reality for the vast majority of people — those regulations are basically meaningless.

Rand Paul also released a potential replacement plan, which is even worse than Cassidy-Collins. It eliminates the requirement that insurance companies cover essential health benefits, walks back the ACA’s push towards universal coverage, and doesn’t protect people with preexisting conditions. Sure, a two-year window of lacking coverage sounds like a reasonable length of time, but if you can’t find a job with benefits for an extended period of time, are a freelancer or independent entrepreneur, or never had health insurance before, you’ve got a problem. Paul’s plan would leave the decision to states in regard to how they handle Medicaid. Those who have already needed to fight for healthcare, like trans folks and those living with mental illnesses, shouldn’t hold their breaths waiting for their states to decide that mental illness care should in fact be covered and that gender identity is not a preexisting condition.

You may also have heard that the Trump administration attempted to sabotage the ACA by ordering that all ads and emails reminding people to sign up for coverage by January 31st stop. He didn’t care that those ads had already been paid for. I just love having my taxpayer dollars wasted, don’t you? It’s a sneaky and callous move to undermine the ACA. Republicans keep talking about a “rescue mission” to “save” the people from an overbearing healthcare system. Actually, the ACA is working quite well. Of course it has kinks and glitches. No one, least of all President Obama himself, ever claimed it was perfect. It’s a starting point and needs improvements. But to claim that it’s “collapsing under its own weight”? My friends, I give you the definition of an alternative fact. If you haven’t enrolled for healthcare coverage already, you can still do so until the end of January. Make sure you get covered, not only for yourself, but to make unraveling the ACA that much harder and more painful for Republicans. They clearly understand how much people stand to lose if they repeal the ACA. Make them own it.

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