Magazine article The New Yorker

Feeling Worse

Magazine article The New Yorker

Feeling Worse

Article excerpt

Feeling Worse

How much of a surprise was the Better Care Reconciliation Act, the Senate's super-secret health-care bill, which Mitch McConnell, the Majority Leader, finally revealed last Thursday? There had been intimations, from President Trump, among others, that it would fix some of the destructiveness of the House bill, which the Congressional Budget Office estimated would cause twenty-three million Americans to lose their insurance coverage. But it turns out that the Senate bill is just as miserable. The new C.B.O. estimate isn't expected until next week, but there are indications that it won't be good: the cuts to Medicaid, for example, may be even more severe than those in the House bill, which the C.B.O. calculated would amount to more than eight hundred billion dollars over the next ten years.

The Senate bill jettisons standards for care so thoroughly that, under its terms, it isn't clear what it would even mean to be covered. Before Obamacare, when people who had insurance developed a serious health condition, they often discovered that it wasn't covered by their policy, or that there were so many co-payments, deductibles, mysterious charges, and caps--including lifetime caps--that their coverage amounted to little more than a discount coupon on something that remained unaffordable. People found themselves without coverage for hospitalization, prescription drugs, and pediatric and chronic-disease care. A key contribution of the Affordable Care Act was to define each of those services, and some others, as "essential health benefits"--services that a plan had to cover in order to call itself a plan.

The House and the Senate bills both allow the states to waive the essential-benefit requirements. House Republicans justified this provision by expressing outrage at the inclusion of prenatal care in the benefits: Why, they asked, should men, who can't get pregnant, have to pay for that? Such attempts to frame access to coverage as someone else's problem are muddled as a matter of both practice and principle.

In America, the category of the vulnerable is a broad one. Medicaid, for example, covers seventy-four million low-income Americans--a fifth of the population. There is no simple picture of this group; according to the Kaiser Family Foundation, thirty-four million are children, eleven million are disabled, and seven million are elderly, a large number of whom live in nursing facilities. Many of those people led middle-class or even affluent lives, until their savings were consumed by the cost of residential care, which, in large part, is not covered by Medicare; nearly two-thirds of nursing-home patients are, at some point, on Medicaid.

One of Obamacare's innovations was to expand Medicaid eligibility to include people slightly above the poverty level. The federal government now pays the states a percentage of what it costs them to care for eligible residents: if a state spends more, it gets more, within certain parameters. Both Republican plans would radically restructure the program, giving states limited sums. The states would then have to use their own money to make up for the shortfall--or they could choose to spend even less. This change would place particularly devastating financial pressures on the elderly, at a time when the population is aging.

Both plans would also strand many people afflicted by the opioid epidemic, a crisis that Trump and other Republicans have promised to address. …

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