Admit it. You don’t know enough about the Better Care Reconciliation Act of 2017 to cast a well-considered vote on its merits. And neither do the people you elected to Congress.
And you may be wondering, why bother? The Senate healthcare bill released last week is unlikely to make it into law intact. On Tuesday, Senate Majority Leader Mitch McConnell delayed a vote until after July 4, apparently because he couldn’t find enough votes to pass the bill.
Even members of Congress sounded helpless this week to do much about the bill. Sen. Bill Cassidy, R-La., said on the “Morning Joe” TV show that he had read 97 of the bill’s 142 pages. He had not had a chance to review the bill as it was being written or to attend hearings.
“I am not going to defend the process,” Cassidy said. “I don’t think the process was the best. On the other hand, I can … curse the wind, or I can put up a sail.”
This is a U.S. senator. All he had to do to improve the process was to convince two of his colleagues to say they would not vote for a bill that had not gone through a proper legislative process. Yet he felt powerless to do anything about it. You should feel much worse.
Striking out to understand the bill on your own is a daunting task. The very first page contains this title: “Elimination of Limitation on Recapture of Excess Advance Payments of Premium Tax Credits.” Not even 200 words into the bill, and I already have to spend half a day figuring out what this means, especially as it applies to “Subparagraph (B) of Section 36B(f)(2) of the Internal Revenue Code of 1986.”
But the bill crafted in secret by 13 senators from just 10 states is close enough to the House bill passed earlier this year that it is likely to become law in some form sometime this year. While most of us have heard the more dramatic numbers associated with the bills—22 million people losing health insurance, $772 billion in Medicaid cuts by 2026—it’s worth a few minutes to look specifically at how the bill would affect Montana.
One way the Senate bill hopes to cut premium costs is by reducing the percentage of medical care that insurance actually has to cover. The Kaiser Family Foundation has attempted an apples-to-apples comparison by comparing the cost of Obamacare’s bronze and silver plans with the cost of the same plans under the Senate bill.
For example, a 40-year-old earning $20,000 on the silver plan would see insurance premiums rise 151 percent if the Senate bill passes. A 60-year-old earning $50,000 would see the cost of a bronze plan rise 571 percent. Even a 27-year-old earning $30,000 would see the cost of a bronze plan rise 11 percent.
In general, according to the Kaiser Family Foundation’s figures, Montana would be worse off in terms of premiums than most other states. Yellowstone County would be somewhat better off than most of the rest of Montana.
Figures from the Center on Budget and Policy Priorities indicate that Montana would be hit with the 10th highest premiums in the country for 60-year-olds on a silver plan making 350 percent of the federal poverty line, or about $42,000. A 60-year-old who makes just above 350 percent of the poverty line would lose nearly $9,600 in premium tax credits, also 10th worst among the states.
A 30-year-old Montanan making 300 percent of the poverty line, or about $36,000, would actually save money under the bill, but 45- and 60-year-olds would still see their premiums go up—by more than $3,000 for 60-year-olds.
Now look at Medicaid. The Montana Hospital Association welcomed Medicaid expansion, which cut the charitable care Montana hospitals give away from $71 million to $39 million in the first half of 2016 compared to 2015. But profit margins also sank from 8 percent to 4 percent during that period, in part because rising deductibles make it harder for patients to pay their bills, and in part because hospitals had to spend more to handle the influx of Medicaid patients.
A study released this month by the Montana Healthcare Foundation looked at the effects of the House version of repeal and replace. The Senate version cuts Medicaid funding a bit more slowly but also a bit more drastically, so the figures should be roughly comparable.
According to the study, conducted by Manatt Health, Montana would lose $4.8 billion, or about 35 percent, of federal Medicaid funding between 2020 and 2026. Of the 79,000 Montana adults who got health coverage under Medicaid expansion, 95 percent would lose coverage.
Montana also is one of eight states with a trigger clause that would immediately end Medicaid expansion if the federal match falls below the match promised in Obamacare.
Making things even worse in Montana is that once the federal government caps Medicaid spending in each state, the Legislature will have to decide how much to budget for Medicaid nearly two years before it knows how much federal money will be available.
The Manatt report estimates that if Montana wants to keep its Medicaid program intact, it would have to cut critical funds for other state programs, such as education and infrastructure. Montana already spends more on Medicaid than it does on transportation and corrections.
How much does Medicaid matter? In Montana, more than 216,000 people were covered by Medicaid in December 2016. Eight in 10 are in working households, and 45 percent were children. More than 3,000 were pregnant women.
Both the Senate and House bills also would cut off all federal funds for Planned Parenthood for one year. In Montana, Planned Parenthood’s five medical centers receive about $1.8 million a year in federal funds and serve about 13,000 patients.
Of course, not all Montanans would be hurt by repeal and replace. Newly elected Rep. Greg Gianforte, R-Mont., would get a tax cut of nearly $800,000, according to a tax attorney’s analysis.
Our two senators are reacting in predictable ways. Sen. Jon Tester, D-Mont., held an online town hall meeting on Tuesday. On Monday, he asserted in a news release that the Senate bill could cost 7,000 low-income and elderly Montana veterans their Medicaid coverage. In addition, more than 7,000 Montana veterans could lose access to treatment for opioid and other substance abuse disorders.
Tester said at the town hall that he has received thousands of emails about healthcare, and they are running 20-to-1 or 30-to-1 against both the House and Senate bills. He mentioned a man in Butte who told him that he had never been able to get insurance that would cover treatment for his diabetes and mental health problems.
Since the passage of Obamacare, the man has gotten treatment for both conditions and now has a good job and is supporting his family, Tester said, defending Obamacare.
“We shouldn’t throw the whole thing out and start over with a bill that’s a whole lot worse,” he said.
Sen. Steve Daines, R-Mont., had an opinion piece in Tuesday’s Gazette that was nearly all about how bad Obamacare is. He said that senators “want to repeal Obamacare and replace it with a health care system that provides more affordable choices, protects those with pre-existing conditions and puts Medicaid on a sustainable path.”
He did not say how the Senate bill would accomplish that.
David Crisp is a longtime Billings journalist and college professor who writes a weekly column for Last Best News.