I have been wondering what I should say about the Republican health care legislation in the Senate. We do know that there is a policy split among Senators about how much and how fast to cut Medicaid. We know the bill will cut taxes. But beyond that there is more information on one of my whiteboards than what is posted in public.
Senate Majority Leader Mitch McConnell is moving this legislation in secret. And there’s a reason. As The Washington Post puts it: “” So McConnell’s theory is that if the Senate’s bill were seen, debated and discussed, opposition would grow and grow, and eventually at least three of his members would bail out (the Republicans’ 52-48 majority means they can only lose two votes). Which might well be true.”
So true in fact that I am not sure which is a worse outcome for Republicans: Failing to pass a bill (ticking off their conservative base) or passing this legislation that by all independent measures will make the US health care system worse.
It’s easy to imagine the coming 2018 election commercials: Millions lose health insurance; health care-related bankruptcies on the rise; and all done in secret so that wealthy campaign donors pay less in taxes.
Indian Country, of course, is largely missing from this debate. There is an assumption that the bill doesn’t impact the Indian Health Service. But Medicaid is growing and it could be, no, ought to be, a significant funding stream for IHS. Even the Trump administration’s budget recognizes that’s budget recognizes that. It projects $914 million in third-party billing for IHS in fiscal year 2018, a slight increase. That’s mostly Medicaid. But the numbers don’t reflect what will happen if that Medicaid money is taken away because the IHS appropriations (which is essentially flat) will have to serve more patients with less resources. Remember half of all Native American children are insured by Medicaid or the Children’s Health Insurance Program.
When the House passed the American Health Care Act a number of “moderate” House members said the bill was bad, but don’t worry the Senate will fix it. Even President Donald J. Trump echoed that idea, telling Senators the House bill was mean and that the Senate should be more generous.
In fact the idea that the Senate would make the bill better was a key part of the House vote. Alaska Rep. Don Young, for example, was said to be a no vote (Alaska gets the worse deal of any state in the House legislation) but ended voting yes. Young told the Alaska Dispatch News two things: First, the bill was moving too fast. And, more important, “this bill we passed today will not become law. It’ll be changed as time goes by. But unless we move it, or move a vehicle, nothing’s going to happen, and that’s not good.”
So process mattered. Then. Now the Senate is engaged in the screwiest legislative path ever; essentially asking Senators to support a blank page. And improving the bill? Hardly. The secret Senate bill is only trying to win with 50 votes, not shape sound public policy.
Every member of the Senate Republican caucus agrees on cutting taxes. That’s the fuel that keeps this bill moving forward. But not all agree about cutting Medicaid (and funding for Planned Parenthood). In a closely divided Senate some members are going to have to take one for the team; vote against their own state interests and voters. Thirty-one states expanded Medicaid coverage under the Affordable Care Act — and twenty of those states are represented by Republicans. All but three have to agree to take away insurance from their voters.
But that’s the easy sell. If there is a long transition period probably nearly all of the 20 Senators will go along. But the conservatives (especially those that represent states that did not expand Medicaid) want a quicker timetable. That means the “moderates” will be going before voters right away and campaigning on less Medicaid for all. That’s terrible politics because the numbers are staggering: Seventy million Americans are on Medicaid. If Congress turns this into a block grant program millions will lose health insurance. Millions of voters.
There are new studies that show how devastating the American Health Care Act would be to public health and the economy. A study by the Commonwealth Fund says nearly a million Americans would lose jobs if this legislation passes. “By 2026, 924,000 jobs would be lost, gross state products would be $93 billion lower, and business output would be $148 billion less. About three-quarters of jobs lost (725,000) would be in the health care sector. States which expanded Medicaid would experience faster and deeper economic losses,” the Commonwealth Fund study found.
Indian Country would lose jobs, too. There are no numbers yet but the Indian Health Service budget would take a significant hit and there would be pressure to reduce the number of employees. Remember the Indian Health system is Indian Country’s largest employer.
The Senate only has a few working days before it’s July recess. If it’s to become law, the bill will need a “score” from the Congressional Budget Office (because of Senate rules this bill must be budget-related). But that won’t happen unless McConnell thinks he has the 50 votes needed to pass. Policy be damned.