Trumpcare 2.0: Just When You Thought It Couldn’t Get Worse, OH LOOK! IT CAN!

First things first, to ensure that it doesn’t get lost in the frenzy that is our current news cycle: let’s be clear about why the Trump administration is so eager to get rid of the ACA and institute Trumpcare. Reason number one: it sets the stage for so-called tax reform, allowing them to give the wealthiest Americans a monumental tax cut on the backs of our healthcare. And since we still haven’t seen Trump’s tax returns, we don’t know how much he stands to gain from this, but we can safely guess a lot. Reason number two: Trump knows that his presidency has been…oh, how shall I put it…SAD, and is desperate to deliver on a legislative promise, no matter how harmful it is to millions of Americans (including his own base, might I add). To add to the drama, he’s racing against the clock as Congress also needs to pass a spending bill next week to keep the government open. 2013 flashbacks, anyone? (And yes, I’d like to point out that that government shutdown resulted from Republican opposition to the ACA as well. Funny, that.)

Trump wants a vote on this plan before the end of his first hundred days, so we could be looking at Trumpcare 2.0 coming to the floor as soon as next Wednesday. Because Republicans rushing a healthcare bill never resulted in a disastrous piece of legislation and embarrassing consequences before, right?

So what’s in Trumpcare 2.0? Thanks to Tom MacArthur, co-chair of the moderate Republican Tuesday Group, the first version of Trumpcare is about to become way worse. It now has a new amendment that allows states to opt out of federally mandated essential health benefits and, in effect, the ban against discriminating against people with preexisting conditions. It doesn’t directly eliminate essential health benefits (things like ambulatory care, hospital care, preventive care, pediatric care, maternity care, prescription drugs, and more — so the entirety of medicine), but in permitting states to decide for themselves what constitutes essential health benefits, it essentially will amount to the same thing for many consumers. What your healthcare covers would come down to the luck of the draw, depending upon in which state you reside.

Now about that discrimination against people with preexisting conditions. Strictly speaking, insurers still won’t be able to flat-out deny coverage to anyone based upon health status. However, as in pre-ACA days, they’ll be able to charge sick people far more than healthy people, which the ACA’s establishment of community rating ended — hence why it’s called the Affordable Care Act. Charging exponentially high premiums to sick people might technically mean that they have access to healthcare, but that’s in no way the same thing as actually being able to afford coverage. I theoretically have access to a luxury European excursion, but it’s not going to happen. Just so for chronically ill people and health insurance, should Trumpcare 2.0 pass. And since states could come up with their own set of essential health benefits, even if you can pay for coverage you might well not be getting anything particularly useful. Remember how the CBO score for Trumpcare The First showed that 24 million fewer people would have coverage as a result? Expect those numbers to plummet further thanks to the MacArthur Amendment, since we’re looking at cost increases in the ballpark of thousands.

Take these two together — letting states waive both federal essential health benefits and community rating — and you’re left with healthcare that’s a) unaffordable for those who need it most, and b) likely not to include basic care. If states can prove that the steps they’re taking would lower healthcare costs, they’d be allowed to let insurers charge exorbitant sums for coverage that doesn’t include what people actually need it to. Community rating is what makes guaranteed issue, which means that insurers have to cover everyone who goes to purchase coverage, tick. Without it, a healthy 30-year-old could purchase insurance for an affordable rate, but a sick 30-year-old could not. And if that sick 30-year-old can’t afford coverage — which is arguably more vital if you’re sick than if you’re well — then there’s no guaranteed issue, since insurers could turn that person away for not being able to pay. Now assume that sick 30-year-old somehow manages to scrape together the money to purchase said coverage. Without federally required essential health benefits, that coverage might amount to little more than an exceedingly expensive piece of paper.

The MacArthur Amendment in practice takes us back to the pre-ACA days when buying insurance was something of a free-for-all, especially if you had the misfortune to be sick. Margot Sanger-Katz provides an excellent breakdown of what that process used to be like, and what that insurance used to cover, prior to when the ACA reformed the insurance market. Bottom line, it was devastating, affixing price tags to peoples’ lives based upon their health statuses through a process called individual rating. Nor did health status only refer to whether or not you were ill; for instance, women who were pregnant would be charged more, and last time I checked, being pregnant is not a disease. Insurance companies required customers to provide all sorts of personal information that could then be used against them, harming their ability to obtain coverage or making them pay through the nose to get it. You couldn’t see prices up front. And there was no standardization of what plans had to cover. Trumpcare 2.0 restores much of this to present reality through granting states the ability to waive these two key ACA reforms.

But wait, that’s not all! In a feat of logic I fail to understand, the MacArthur Amendment tries to make up for permitting insurers to charge exorbitant premiums to people with preexisting conditions by requiring states that waive community rating to institute high-risk pools. To make a long story short, high-risk pools do not work. Think about it logically: throwing all of the people with the highest medical costs together will result in even higher medical costs. That’s exactly what the individual mandate seeks to circumvent by spreading costs evenly among the populace. High-risk pools also often come with a waiting list as a measure to lower costs, are unaffordable for many, and don’t provide good coverage anyway — all the more problematic if you’re already sick and therefore require solid coverage. And if they’re grossly underfunded as is likely, they don’t do much good to anyone. Given that Trumpcare 2.0 cuts Medicaid funds, it’s reasonable to expect that it won’t really help states’ high-risk pools either. Sure, okay, there’s nominally now Trumpcare’s “invisible risk-sharing program,” but it’s aptly named, as it’s so poorly funded that it’s virtually invisible. Republicans’ promise that all people will be able to obtain coverage rings awfully hollow.

Even if moderate Republicans and Freedom Caucus members manage to coalesce around Trumpcare 2.0, it may contravene the rules of reconciliation. While reconciliation seems like the Republicans’ magic bullet because it allows them to pass legislation with only a simple majority, it also means that that legislation has to be directly relevant to the federal budget — so tinkering with insurance regulations are a no-go. At the same time, given Republicans’ willingness to go nuclear on Gorsuch, it’s easily conceivable that they’d ignore any parliamentarian objections. As per usual, Republicans have to figure out how to deal with their in-fighting, but the pressure is rising from the White House to get this done.

It’s also vital that we don’t lose sight of non-legislative threats to the ACA. Trump and Price have already taken a hammer to the ACA and show every sign of continuing. Already, Trump threatened to hold cost-sharing reduction payments hostage, spooking insurers to the point that numerous counties and even states could be left without any coverage options for 2018. He also issued destabilizing new rules that further impede people’s ability to purchase meaningful coverage by halving the enrollment period so that it ends in the midst of the holiday season, lessen the quality of coverage, and charge consumers more for that poorer quality coverage — so basically the Trump University of healthcare, except it’ll be harder to purchase.

If a lot of this feels like deja vu, you’re not alone. We’ve been down this path before — and we’ve won. We’ve got another battle ahead of us, one that we’re now fighting on multiple fronts. So get those dialing and typing fingers warmed up to speak out and #ProtectOurCare! Millions of Americans are counting on us, and we cannot let them down. Once and for all, let’s make it absolutely clear that healthcare is a human right, and that we will not go back!