Facing a Sept. 30 deadline to pass legislation to repeal and replace the Affordable Care Act of 2010 (ACA), Republican Sens. Lindsay Graham and Bill Cassidy are vigorously pushing a proposal (GCA) to overhaul America's health care system. Sens. Dean Heller and Ron Johnson are co-sponsors.
Under Senate rules, this measure can be approved by a simple majority before month's end. A 50-50 tie could be broken by the affirmative vote of Vice President Mike Pence. House Speaker Paul Ryan promises immediate approval by the House if the Senate bill beats the deadline.
Given the rush to a vote in the Senate, there is little chance that public hearings can be held to analyze the GCA and to debate its merits and shortcomings. Provider and patient groups will have no opportunity to voice their concerns. As of Sept. 21 , opposition to the GCA has been expressed by the American Medical Association, the American College of Physicians and the American Academy of Family Practice.
Organizations opposing the GCA include the American Cancer Society, American Diabetes Association, National Lung Association, Arthritis Foundation and National Organization for Women. The AARP has added its strong opposition. America's Health Insurance Plans foresees chaos if the GCA passes. Lists of opponents will grow as content of the ACA is publicized.
Dr. Clif CleavelandNormally, the nonpartisan Congressional Budget Office (CBO) carries out a detailed analysis of cost and impact for important pieces of legislation. A full CBO report on the GCA is impossible before the Sept. 30 deadline.
Many provisions of the GCA do not go into effect until 2020, deliberately placing them beyond midterm congressional elections of 2018. Incumbents who supported the bill would be spared explaining future, major cuts in health care funding for their constituents.
Major components of the GCA include:
* Individual mandate. The requirement to obtain health insurance is repealed.
* Employer mandate. Large employers who fail to offer affordable health insurance to workers are no longer penalized.
* Medicaid, which provides support for more than 70 million Americans, is radically altered by substantial cuts in funding. In addition to support for people living in poverty, Medicaid provides health coverage for millions of elderly people in nursing homes.
Money allocated to the 32 states and District of Columbia that chose to expand their Medicaid programs will be folded into block grants for individual states beginning in 2020. Each state must decide how to utilize that money by the end of 2018. For example, a state might choose to develop a single-payer program. Another state might devise a program involving multiple payers.
In the interval 2020 to 2026, total funds allocated for block grants will be more than $8 billion less than under current law.
A per-capital cap on Medicaid expenditures will be applied.
Childless couples will not qualify for coverage.
Block grants will have varying effects upon individual states. Alaska, California, Connecticut, New Hampshire, New Mexico, New York and Washington will see a 25 percent reduction in Medicaid funding promised by the ACA. Twenty-seven additional states will see varying cuts in federal support for their Medicaid programs. Texas, Alabama, Mississippi, Georgia, Tennessee and other states that chose not to expand their Medicaid programs under terms of the ACA will realize increased federal funding. GCA, in effect, punishes states that chose to expand health care benefits for poor people.
Block grants will have strings attached. Individual states, however, may apply for waivers that eliminate these requirements. A state could seek a waiver for people with pre-existing medical conditions so that they could be placed in a high-cost, high-risk pool. A state might choose to eliminate or to limit mental health care. No-cost access to birth control pills could be chopped. Each state would determine which essential health benefits, such as recommended vaccinations and health screenings, to include in its Medicaid program.
Some states may design successful health care programs. States that in the past provided skimpy benefits to a small percent of poor residents might improve care or change nothing.
* Premium support. The GCA eliminates subsidies for people earning up to 400 percent of the federal poverty level, an important component of the ACA that makes health insurance affordable for millions of people. A state might choose to use a portion of its block grant to replace some of these subsidies.
* Tax credits. The ACA included tax credits that helped people with limited incomes and high medical expenses to purchase health insurance. These disappear with the GCA.
* Health saving accounts. Tax-free contributions will be increased to promote their use by more people.
An excellent summary of GCA can be found at Kaiser Family Foundation (www.kkf.org).
Our health care system is extremely complicated and accounts for 17 percent of gross domestic product. The health and lives of countless Americans depend upon predictable, affordable, accessible health care. In place of uniform, federal requirements under the ACA, the GCA will create a hodgepodge of 51 plans. The GCA aims to control runaway costs by applying a system of rationing upon those people with limited incomes.
In my opinion, the tactics to ratify the GCA represent legislative malpractice.
Many years ago, at a lecture at the University of Tennessee at Chattanooga, Duke University ethicist Harmon Smith posed this question: "Who gets how much of what when there is not enough to go around?" We are still searching for an equitable answer.
Contact Clif Cleaveland at ccleaveland@timesfreepress.com.