IMPORTANT CLARIFICATION: ALL ESTIMATES BELOW are based on the CBO score of the HOUSE GOP version of the Trumpcare bill (AHCA). The CBO's score of the SENATE GOP version (BCRAP) just came out on 6/27/17, and hasn't been broken out by Congressional District yet.
UPDATE: ALL 435 CONGRESSIONAL DISTRICTS NOW INCLUDED (broken out by state)
As regular readers know, earlier in the year I embarked on a project to break out the total number of people who would likely lose their healthcare coverage if & when the ACA were to be fully repealed without any replacement whatsoever (i.e., a "clean repeal"). When the dust settled, I estimated the grand total would come in at around 24 million people. I broke this out by state and even attempted to do so by both County and individual Congressional District. Since the GOP hadn't actually come up with any sort of a replacement plan for the ACA, I could only assume that they had a "clean repeal" in mind and work it from that angle.
A few months ago, tech/media journalist Simon Owens interviewed me for a profile piece he wanted to write about ACASignups.net...basically, the whole story of how a Michigan website developer somehow became a national data/analysis source for All Things Obamacare. I had a couple of similar stories written about myself and the site by Sarah Kliff of Vox and Miranda Neubauer of TechPresident, but those were both over 3 years ago, in the midst of that insane first Open Enrollment Period, when the site was at peak media attention. I've been cited/quoted quite a bit since then, but most of that has been about the actual data and analysis, which of course makes sense.
They've once again taken the CBO's total estimates for net coverage losses as of 2026 (15 million nonelderly people losing Medicaid, 7 million losing individual market coverage) and done their best to break that 22 million total out by state, district and even the type of Medicaid coverage (Adults, Children, the disabled and ACA expansion), along with the million or so elderly Medicaid enrollees who would likely lose partial coverage (they'd still have Medicare but lose Medicaid). I'm once again taking their raw data and reformatting/color coding it into individual state-level infographics, suitable for sharing via social media.
I've had to spend most of the afternoon/evening taking care of my kid (he has a 2-hour karate class Monday evenings), so I'm just now getting a chance to actually read the CBO's score of the GOP Senate's BCRAP bill, beyond their general summary of the score which I simply posted verbatim (with a handful of highlights and notes) earlier today.
There's a lot to digest; I'm sure everyone's already heard the main lowlights/takeaways: 22 million losing coverage by 2026 (14 million kicked off of Medicaid, 7 million losing individual market coverage, 1 million miscellaneous/rounding, I presume), "deficit savings" of around $321 billion (giving Mitch McConnell $202 billion to try and buy the votes he needs from a handful of "moderate" Senators) and so on. I'll be writing my full analysis for tomorrow, though there's probably not much point in it, since every other healthcare reporter will already have beaten me to the punch.
However, there's one little bit which infuriates me so much I have to get it off my chest right now. But first, the setup:
(I don't have time for a full analysis right now, so I'm just highlighting some key points and making a couple of notes for the moment...plenty of other reporters/bloggers/wonks are furiously writing analysis right now as well, of course)
The Congressional Budget Office and the staff of the Joint Committee on Taxation (JCT) have completed an estimate of the direct spending and revenue effects of the Better Care Reconciliation Act of 2017, a Senate amendment in the nature of a substitute to H.R. 1628. CBO and JCT estimate that enacting this legislation would reduce the cumulative federal deficit over the 2017-2026 period by $321 billion. That amount is $202 billion more than the estimated net savings for the version of H.R. 1628 that was passed by the House of Representatives.
Louise Norris gave me a heads' up regarding the Indiana 2018 rate filings. Anthem BCBS and MDwise, which currently have around 46,000 and 30,800 exchange enrollees each, are dropping out next year, meaning nearly 77,000 people will have to shop around. Anthem is sticking around the off-exchange market....but only in a handful of counties. Norris indicates around 64,687 total Anthem enrollees; minus the 46K on-exchange, that leaves roughly 18.7K off-exchange enrollees, virtually all of whom are expected to drop due to Anthem dropping out of all but 5 counties (plus, of course, the large rate hike).
The other day it looked like the GOP Senate's BCRAP bill was going to take a hatchet to all 3 legs of the ACA's "three-legged stool", by getting rid of some provisions outright (CSR assistance and the Individual Mandate), weakening and slashing others in half (premium tax credits) and, most cynically, allowing virtually open-ended waivers which would allow individual states to wipe out many others (essential health benefits, minimum AV ratings, annual/lifetime benefits and the ACA's cap on maximum out of pocket costs). Here's what I figured this would make the "stool" metaphor look like:
So, like everyone else, yesterday I was poring over the BCRAP text, and one of the first things which caught my eye was the individual market tax credit structure table, to see how it compares with the ACA's formula. Here's how it stands under the ACA...again, these percentages are based on the benchmark Silver policy...
...and here's the BCRAP table, based on the benchmark Bronze policy:
After reviewing it for a few minutes late yesterday morning, I posted a tweet noting that under the ACA, a 60-year old earning about 300% of the Federal Poverty Line...roughly $37,000/year...only has to pay up to around $3,600/year in premiums for a Silver plan (9.69% of their income)...but under BCRAP, that same 60-year old would have to pay up to $6,000/year for a Bronze plan (16.2% of their income).
The tweet went viral...I think it was retweeted like 1,000 times or so over the next few hours.
a) The Parliamentarian is most likely going to be stripping out significant non-germane to the budget items
b) $1 billion in savings must come from each of two committees (HELP and Finance)
c) Anything the Senate passes must meet or beat the $119 billion in budget window deficit reduction that the House AHCA was scored at.
However, from a political POV, the bigger question is how many people the CBO projects will lose coverage by 2026 if BCRAP becomes law.
OK, this metaphor will take a bit, but bear with me.
On March 16, 1981, CBS aired the 17th episode of Season 9 of M*A*S*H. For those of you too young to remember, M*A*S*H, set at a U.S. Army medical camp in Korea during the Korean War, was one of the most successful TV shows in history, running 11 seasons. I believe the series finale remains the most highly-viewed broadcasts in history. While M*A*S*H started out primarily as a sitcom, it evolved over the years into more of a drama with comedic moments.
Anyway, in S9 Ep17, "Bless You, Hawkeye", the main character, Dr. Benjamin Franklin "Hawkeye" Pierce (played by Alan Alda) finds himself stricken with a sudden, unexplained and violent allergic reaction to something. He spends much of the episode trying standard medical solutions, but his fits of sneezing and coughing become so bad that eventually a recurring character, psychiatrist Dr. Sydney Freedman, is brought in to see if there might be a psychological cause.
Freedman asks Hawkeye about his childhood, and Hawkeye, among other things, mentions his cousin Billy.
Back in 2011, when Paul Ryan and House Republicans first attempted to privatize Medicare, a progressive PAC ran the ad above. In it, "America the Beautiful" plays as we see a young, Paul Ryan-ish looking young man pushing an elderly, wheelchair-bound woman down a nature path...and eventually pushing her right off of a cliff. Needless to say, it caused quite a bit of controversy at the time.
Earlier today, as the GOP Senate's BCRAP bill was released, this happened:
I spent almost all of Part One discussing the butchering that the GOP Senate's BCRAP bill does to the individual market, because that's the primary focus of my work here at ACA Signups, but the truth is by far the worst fallout will be on the Medicaid side of things...and most of the damage doesn't even have a damned thing to do with the ACA itself, since it relates to pre-ACA Medicaid.
I'll get to the Medicaid side in depth in Part Three. However, there are still a few more things I need to discuss regarding the individual market: The sub-100% FPL population and how it relates to Medicaid expansion.
There's a lot to absorb here, but this is the bottom line:
MEDICAID: It's MORE draconian and cruel to Medicaid enrollees than the House version...but delays the worst of it by a few more years.
Seriously, that's it in a nutshell. It phases out the ACA's Medicaid expansion more gradually...but as the years pass, would eventually squeeze even more people off their coverage...mainly via non-ACA Medicaid, which means that this bill really has little to do with "repealing Obamacare" and is mainly about giving massive tax cuts to the ultra-rich at the expense of the poor and low-income workers.