UPDATED x2: Trumpcare 2: Electric Boogaloo is here...and it's even worse than before!

Too cowardly to kill off pre-existing coverage directly, GOP dumps it on the states.


Immediately after the "death" of the AHCA (Trumpcare) bill, I posted the clip above (from the underrated suspense thriller "Dead Again"), noting that as much of a victory as it was, there was little time to pat ourselves on the back, because Trump and the GOP would no doubt be back for Round 2 at any moment.

At the time, I assumed that they would likely abandon the "official" attempt at repeal/replace for the time being, and focus instead "only" on sabotage efforts of the ACA itself by doing whatever they can to scare off the carriers...and for the most part, that's exactly what Trump has done ("It's gonna explode!" and so forth).

However, it appears that "the time being" meant "less than two weeks", because they're already trying to bring the AHCA back...and not only is it just as horrible as it was two weeks ago, it's actually worse, as noted by Margot Sanger-Katz of the New York Times:

...the proposed changes would effectively cast the Affordable Care Act’s pre-existing conditions provision aside.

The terms, described by Representative Mark Meadows, Republican of North Carolina and the head of the Freedom Caucus, are something like this: States would have the option to jettison two major parts of the Affordable Care Act’s insurance regulations. They could decide to opt out of provisions that require insurers to cover a standard, minimum package of benefits, known as the essential health benefits. And they could decide to do away with a rule that requires insurance companies to charge the same price to everyone who is the same age, a provision called community rating.

The proposal is not final, but Mr. Meadows told reporters after the meeting that his members would be interested in such a bill. To pass the House, any bill would need to find favor not just with the Freedom Caucus, but also with more moderate Republicans. It would also need to attract the support of nearly every Republican in the Senate to become law.

"Guaranteed Issue" is the term used for requiring carriers to cover people with pre-existing conditions. The GOP is going to claim that they're keeping guaranteed issue...but killing off essential health benefits (EHBs) and community rating has the exact same effect in practice as killing guaranteed issue, in two ways:

  • Killing community rating would let them charge those with pre-existing conditions pretty much whatever the hell they want to. "Got cancer? Sure, we'll offer you access to the same policy as everyone else...it'll just cost you 100x as much as other people to get it, that's all! That'll be $50,000 per month, please!"
  • Killing the EHB requirements would allow the policies themselves to be utterly meaningless, since they wouldn't necessarily cover a damned thing. "We don't discriminate--anyone can buy our policies! Of course, they don't actually cover maternity, prenatal care, mental health services, outpatient procedures, Lyme's disease, fibrocystic conditions, cancer treatment, diabetes, prostate screenings, hospitalization, ambulatory services or surgery...but you're guaranteed access to buy the policy itself!"

This actually isn't all that different from the (final) final version of the first Trumpcare go-around from the night before the pulled vote two weeks ago, which also would have stripped out the EHB requirement (and then would've thrown $15 billion back into the mix, one time only, to supposedly cover the 2 EHBs which people were screaming about the loudest at the time: Maternity and mental healthcare coverage).

The main twist here is that apparently instead of wiping out the EHB requirement nationally, this would "only" allow that decision to be up to the individual states. On the surface, this may not sound as bad (maybe only HALF the states will screw over their most vulnerable residents instead of ALL of them!), but considering how crappy the AHCA's overhauled tax credit system would be (along with it also kicking millions of people off of Medicaid), even the states which don't want to kill EHBs or community rating would pretty much have no choice but to do so. As Sanger-Katz notes:

What states would choose to do with this set of options is hard to predict. Before Obamacare, few states required community rating of health plans. And few states required insurers to cover all of the benefits deemed essential under Obamacare, though most did require a few types of treatments to be covered. State governments would face a difficult choice: either take away the requirements, and leave sick patients without insurance options, or keep them and see people unable to afford coverage under the new subsidy system.

But wait, there's more! Assuming the GOP's longtime "letting insurance policies be sold across state lines" obsession were to also be included and implemented, this would also make the "decision" of states to keep Essential Health Benefits mandatory utterly meaningless, since their residents would also be able to buy junk plans from across the border...which in turn would weaken the EHB state's risk pool even further! Double win! (that's sarcasm).

So, what might these "insurance policies" actually consist of? Well, as I noted back in December, they might look something like the following:

For example, McDonald’s”McCrew Care” benefits...requires employees to pay $56 per month for basic coverage that provides up to $2,000 in benefits in a year and $97 per months for a Mid 5 plan that provides up to $5,000 in benefits. Ruby Tuesday charges workers $18.43 per week (going down to $7 after six months of service) for coverage that provides up to $1,250 in outpatient care per year and $3,000 in inpatient hospital care. Denny’s basic plan for hourly employees in 2010 provided no coverage for inpatient hospital care and capped coverage for doctor office visits at $300 per year.

Wow, $2,000 in benefits per year? Awesome! That's enough to cover...um...one day in the hospital per year, and absolutely nothing else whatsoever!

The "good" news, such as it is, is that the Congressional Budget Office (again, from December) is having absolutely no part in this nonsense:

Some policymakers have expressed interest in developing proposals to replace the current tax-based subsidies for the purchase of private health insurance in the nongroup (or individual) market under the Affordable Care Act (ACA) with refundable tax credits that would be structured differently from those under current law. Many such proposals would also eliminate or reduce the extent of current federal laws regulating the nongroup market, particularly the rules governing health insurance benefits. Two key questions for policymakers in developing such proposals are what type of insurance products would qualify for tax credits and what role states would have in making that determination.

...In response to a future policy that had minimal federal or state regulations, CBO and JCT expect that some new insurance products would be offered that limited coverage to the amount of the tax credit. Some of those insurance products purchased by people using a tax credit would probably not offer much financial protection against high out-of-pocket costs. Depending on the size of the tax credit, however, the depth and extent of coverage and the premiums of plans could vary. As discussed in another blog post about how CBO defines and estimates coverage, CBO does not count plans that have very limited benefits in measuring the extent of private insurance coverage; in such an assessment, it counts only people with a comprehensive major medical policy as having private insurance.

Under such proposals, CBO and JCT would separately estimate the number of people who would receive the tax credits and, if policymakers expressed interest in such estimates, the number of people who would purchase private insurance in the nongroup market that met a broad definition of coverage. In that case, the latter estimate of the number of people with coverage would probably be smaller than the estimate of the number of people who would receive the tax credit.

In other words, the CBO warned the GOP quite emphatically that they better not try peeing on everyone and claiming that it's rain. Then again, I thought golden showers were Donald Trump's specialty.

UPDATE 5:00pm: Or...never mind?

Trumpcare revival talks falling apart ahead of Pence meeting

Attempts to reach a deal this week on health care are unraveling fast, with conservatives already blaming House Speaker Paul Ryan for blocking the White House bill, and leadership sources saying that's nonsense and that the Freedom Caucus is making unreasonable demands that are losing net votes.

It's a bad sign for Republicans ahead of Vice President Mike Pence's visit to the Capitol tonight. From a senior Republican source:

"While we haven't picked up any votes yet, this concept is already showing signs of losing a ton of them."

 It seems my decision to use a clip from the movie "Dead Again" was a bit more on the nose than I intended...

UPDATE 7:00pm:

Pence, joined by Priebus and Mulvaney, suggested the WH is serious about a vote on healthcare this week, per one attendee

— Rebecca Berg (@rebeccagberg) April 4, 2017

...or perhaps not.

Wash, rinse, repeat.

All the GOP has to do is keep jerking the insurance carriers around for 78 more days and Donald Trump's openly, repeatedly stated goal of intentionally causing the ACA exchanges to collapse and "explode" (wouldn't that be implode?) will come true...because I can't imagine any carrier will be willing to commit to participating next year when they have absolutely no clue what the ground rules are going to be for the 2018 individual market landscape.