This blog is part of a series that will highlight how structural racism in the health care system negatively affects the health of individuals of color. Community Catalyst is committed to exposing and dismantling policies, practices and attitudes that routinely produce cumulative and chronic adverse outcomes for people of color in the health system.

The Better Care Reconciliation Act (BCRA) would result in 22 million people losing their health care coverage over the next decade, cause long-term damage to the Medicaid program and raise health care costs to extremely unaffordable levels for consumers. Millions of low-income people of color, especially those with chronic health conditions, would be among the hardest hit. A recent analysis conducted by the Urban Institute estimates that by 2022 roughly 21 percent of those who would become uninsured because of BCRA are Latinos, and 12 percent are Black. This bill would reverse racial health equity gains made under the Affordable Care Act (ACA) and strike a blow against signature victories for racial equality in America.

Massive cuts in Medicaid would cause millions of people of color to lose coverage

According to the Kaiser Family Foundation, more than one in five adults of color and nearly six in ten children of color are currently enrolled in Medicaid. Medicaid represents an important source of insurance coverage for low-income people of color who are more likely than whites to work in low-wage jobs that provide limited access to employer-sponsored insurance. The program is a vital tool for states to respond to fluctuations in unemployment, public health crises and changes in population growth many of which disproportionately affect people of color. Yet, according to the Congressional Budget Office, the BCRA would cut as much as 26 percent of Medicaid funding ($772 billion) over the next decade, which would hamstring state programs and budgets. Specifically,

  • The BCRA would effectively end Medicaid expansion, putting at least 15 million low-income people at risk of becoming uninsured and losing access to the care they need. For people of color, eliminating Medicaid expansion would leave as many as 1.5 million African Americans and 3.3 million women of color without health insurance or enrolled in extremely expensive private options with deductibles as high as half of their annual income.
  • The BCRA would permanently convert Medicaid to a per capita cap funding system, which would not keep up with the underlying costs of the program. Because of massive losses in Medicaid funding, states would be forced to cuts costs by eliminating essential programs and services people of color are dependent upon. Many rural hospitals would be forced to close down. Particularly in southern states with centuries’ worth of social and structural inequalities, African Americans and Latinos who have already experienced worse health outcomes would have to travel longer distances for essential and preventive care or die from emergency conditions (like accidents or heart attack).

Allowing states to drop the Essential Health Benefits (EHB) for private insurance, leaving millions of people with pre-existing conditions without essential coverage 

On average, people of color experience shorter life spans, higher infant mortality rates and higher prevalence of many chronic conditions compared to whites. This bill would take away access to critical care services (including prenatal and maternity care, chronic disease management and treatment for mental health and substance use disorders) from people of color who face serious physical, mental and behavioral health problems.

Eliminating the Prevention and Public Health Fund would cut supports to low-income and vulnerable communities

The BCRA would end the appropriations for the Prevention and Public Health Fund, which would directly affect everyday Americans and their families living in low-income and underserved communities. Facing massive cuts in Medicaid and prevention funds, states would be unable to prevent the onset or spread of infectious diseases (such as measles, zika and ebola) and redress long-standing inequities in health and safety by investing in communities with greatest needs.

The BCRA is dangerous for millions of low-income and vulnerable Americans. The combined effects of the BCRA have devastating and long-term impacts on the health and economic security of communities of color. We need to keep up our pressure on Republican Senators and plainly call out the damaging impacts this bill would have on their constituents.

Despite his best efforts, Senate Majority Leader McConnell couldn't coax a ‘yes’ vote out of 50 of his 52-member caucus before the July Fourth recess. The path forward for McConnell and the Senate Republicans seems to revolve around trying to move in two directions at once – more money for the more centrist party members coupled with more insurance deregulation for the far-right -- while continuing to mislead the public about the true content of the bill.

Here's a closer look at why the Senate bill stalled and what steps are being taken to revive it, along with some notable bits and pieces from the recent debate.

Why McConnell couldn't get to ‘yes’ before the Fourth

The push for a vote before the Fourth ran aground on a combination of internal Senate dynamics and external forces. As far as internal dynamics go, roughly three groups of senators blocked the path to a Senate vote. One group, typified by senators Heller and Collins, expressed concerns about the damage the legislation would do to the health care system in their states; Other senators, Such as Ron Johnson from Wisconsin, were unhappy with the process and wanted more time to evaluate the bill. Finally, senators like Ted Cruz and Rand Paul did not believe that the bill did enough to roll back the ACA or to undermine the Medicaid program. Key external forces were also critical in giving senators pause. Especially important were the popular mobilization against the bill, as well as the rising tide of stakeholder opposition. Absent these external forces, there is little doubt that the Senate would have swallowed its doubts and voted.

Where does the bill go from here?

In order to win over wavering moderates, one possible option being debated is to dial back on some of the tax cuts in the bill. For example, some senators seem to support abandoning at least some the tax cut for wealthy individuals (while keeping the cuts that affect the health care industry). This would restore about $170 billion in revenue. Adding this amount to the $188 billion they already have in hand to spread around (the difference between the House’s deficit-reduction score which they have to meet, and the score of Senate bill), they could attempt to win over some of the holdouts. The problem is that the Senate bill cuts around $1.2 trillion from the health benefits of low- and moderate-income people. Putting back less than one-third of that amount still leaves a bill with deep, devastating cuts (that fall hardest on communities that voted for Trump, by the way) – still a mean bill by any estimation – while also potentially losing votes on the far right in both the Senate and, ultimately, the House.
 
Another route Senate Republicans may attempt is to double down on their efforts to improve the optics of their bill without actually making it any better. For example, thanks to various efforts to undermine the functioning of the ACA, there has already been a decline in the number of people covered since Trump took office. Some senators have come up with a novel tactic: asking the CBO to change the base year on which they calculate coverage losses from 2016 – as has been used through the House legislative process and to date – to January 2017, so that the coverage loss numbers would “look” smaller, even though the number of people without insurance would be exactly the same. Of course, it was the Republican-controlled Budget Committee that picked 2016 as the base year to begin with and even many conservatives have already come out and criticized this effort to “cook the books.” Moreover, given CBO’s customary aim to compare “apples to apples,” they are unlikely to make this base year change, so the success of this gambit is highly doubtful.

In addition, they already have tried this with without success with respect to their approach to Medicaid – the more gradual elimination of Medicaid expansion funding in the Senate compared to the House’s still lands us at exactly the same place as the House bill, just on a slightly different timeline. The Senate also tried to hide their even more draconian Medicaid cut by having it not take effect until the end of the CBO’s standard 10-year analysis window. But the CBO wasn't having it and released a follow up analysis on June 29 (thanks to a request from Senator Wyden) showing that Medicaid would be cut by over a one-third as a result of the Senate bill. As the National Association of Medicaid Directors noted in its statement, no possible degree of administrative flexibility could compensate for this magnitude of cuts. Rates, services and eligibility would all have to be drastically curtailed, with severe consequences not only for beneficiaries but for major parts of the health care system. Providers are now figuring that out, as evidenced by the recent uptick in engagement by groups such as the nursing home industry which had previously been sitting on the sidelines.
 
Finally, the Senate is considering an amendment that would recreate an alternative insurance market without vital consumer protections the ACA affords, such as minimum benefit requirements and the ban on charging sick people higher rates. This would be a disaster that would almost immediately turn the plans offered on the Exchanges into a high-risk pool with premiums that would be unaffordable for anyone who didn't qualify for significant financial assistance.

Forget what he said yesterday

"Repeal now, replace later,” (maybe) may be making a comeback?  Trump is calling for a straight repeal with no replacement if the Senate can't agree on a replace strategy. While the president may have forgotten (or simply doesn't care) that he panned this strategy just a few months ago, there is a reason the idea was rejected. A straight repeal bill has a devastating effect on the number of people insured and on the health care industry.
 
Ironically, of course the "replace bills" offered by each chamber haven't been much better than straight repeal. That's because the essence of “straight repeal” is to eliminate the ACA revenue streams and pay for that lost revenue by cutting benefits. Each iteration of the bill has preserved this core mechanism and so each one causes large coverage losses and economic harm to providers and states. Therefore, the same logic that led to the rejection of "repeal without replace" should lead to rejection of any of the replacement options offered so far. (Of course, the role of logic in this debate is severely constrained.)
 
More ironically, the replace bills actually do more damage to Medicaid beneficiaries than does a straight up repeal. Both a straight repeal and the replacement plans end the enhanced financing for the Medicaid expansion, but the replacement bills go further and cut coverage for children, people with disabilities and older adults. Some Republicans have tried to defend their Medicaid cuts by claiming they are needed to control the federal deficit. The fact that most of the Medicaid cuts are used to pay for tax cuts rather than deficit reduction reveals the utter hollowness of this claim.

Looking ahead

If  McConnell thought there was no chance of getting to ‘yes,’ he would have brought up the bill already in order to clear the decks for other business. We can, therefore, be pretty certain that the Senate will take another run at passage in the next couple of weeks. But time is running out on repeal (not as a procedural matter, but as a practical one for GOP leadership). There is a crowded congressional calendar with tax reform, raising the debt ceiling and 2018 appropriations all on tap. Some senators have already called for shortening or canceling the August recess to address the pile up. Trump's attempt to revive repeal without replace smacks of desperation. All in all, this means the next several weeks a critical make or break point. Blocking the repeal effort now won't make the problems in the health care system go away, but it will substantially change the starting place from which we can address those problems.

Bits and Pieces…

When too much is not enough
 
Sheldon Adelson seems pretty unhappy with Senator Heller and it’s no wonder. If BCRA passes, the Nevada billionaire gets a $48 million per-year tax cut (and lord knows he needs another $48 million), so Heller's opposition to the law based on the cuts it would impose on people on Medicaid and who lack ESI was a blow. Does seem like a tough call, doesn't it? – tax breaks for billionaires or health care for kids, seniors and people with disabilities – but Sen. Heller seems to have figured it out (at least for now). Let's hope more of his colleagues reach the same conclusion.

They just don't get it

It is simply mind blowing that "men shouldn't have to pay for maternity care" remains a talking point among those pushing to scrap the Essential Health Benefits (EHB) protection in the ACA. It seems like people making this argument don't understand the principle of risk-sharing that is essential to any insurance market. Further, it seems like an obvious national priority to ensure that the next generation gets a healthy start and has fewest possible medical complications at birth. Yes, this could be achieved with a universal program covering maternity care and delivery, but that is not what opponents of EHB are advocating. Instead, they are simply proposing that men be exempt from sharing the cost of maternity care. Which leads me to speculate that, in addition to being unclear on how insurance works, they are also unclear on the "facts of life." Someone needs to sit them down for a little talk – “no, the stork didn't bring you.”

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.

As Congress heads home for its July 4 recess, the Republican Senate leadership remains determined to press toward a July vote on a bill that would eviscerate Medicaid and repeal the Affordable Care Act (ACA). Despite assurances to the contrary, the Senate’s Better Care Reconciliation Act closely mirrors the massively unpopular American Health Care Act passed in May by a narrow Republican majority in the House of Representatives. What many members of Congress and their constituents may not realize is that war veterans and their families will also be among the millions of seniors, individuals with disabilities and working age men and woman seriously hurt by this legislation.

All told, 1.8 million veterans rely on Medicaid health care, services and support – 340,000 of whom gained access to Medicaid thanks to federal funding under the ACA that enabled 31 states and the District of Columbia to close gaps in health care coverage. This number does not include the 1.5 million family members of veterans who are not eligible for VA care and who solely rely on Medicaid for health care services.

We now know that there is a much larger percentage of veterans living with a daunting array of war-related physical and psychological wounds than was previously understood. According to a 2014 non-partisan Congressional Budget Office analysis, 44 percent of the 2.7 million veterans who served in Vietnam, and 43 percent of the 1.6 million veterans who served in the Gulf War, Iraq and Afghanistan have recognized service-related disabilities that will require ongoing care for the indefinite future. Care today that is predominantly provided by the VA system or through Medicaid.

Army veteran and Gold Star wife Sylvia Earhart of Colorado Springs, Colorado knows all too well what veterans stand to lose if the Senate bill becomes law. Sylvia’s son has Down’s syndrome and autism, and Medicaid provides the care he needs. He has a hole in his heart, his hips needed severe reconstruction – requiring him to use a wheelchair – and he’s undergone countless surgeries over the years. The nearly $840 billion in Medicaid cuts in the Senate has proposed could not only end critical services, including school and home-based support services that support his continued development, but also impede his access to care. 

Where will our veterans like Sylvia and her family get the care that they need in the future?

While the VA system provides excellent care for veterans dealing with the physical and psychological “wounds of war,” many veterans are unable to access VA facilities, because such facilities are unevenly distributed across the country. Rather than expand the VA system, President Trump’s hiring freeze has contracted it. With 40,000 (and rising) unfilled VA clinical and support positions, the increasing barriers to access are forcing veterans to reluctantly end trusted relationships with VA clinicians and seek care “elsewhere.”

However, if the president and most Republicans get their way and eviscerate Medicaid, there would be no “elsewhere” to go to. There would be no guarantee of Medicaid to support needed services and there would be a nearly $840 billion cut in federal Medicaid funding, leaving the states to fend for themselves. Thus, the combination of the VA hiring freeze and the dismantling of Medicaid is nothing less than a “declaration of war” on our wounded veterans. There is no other way to say it.

Rightly or wrongly, our nation has asked our veterans to make extraordinary sacrifices as well as endure suffering and loss that for many will last for a lifetime. Our veterans deserve all the care and services that can best heal their psychological and physical wounds. It now falls to the Senate to affirm without ambiguity that it will meet America’s obligation to our wounded veterans as well as to the millions of Americans who will be harmed in the rush to dismantle critical components of our health care system.

Robert Master, MD, is the founder and president and CEO emeritus of the Commonwealth Care Alliance and captain U.S. Army MC, 101st Airborne Division, Vietnam (1969-1970)

Take a moment to imagine that someone you love, maybe an aging parent or grandparent, was just released from the hospital after an illness. What kind of care would you want them to receive? Would you want them to be able to recover safely in their own home, near their loved ones?  Would you want them to have someone who could help them manage complicated instructions from all the different doctors they’ve seen? How about access to things like meal delivery services and transportation to follow-up appointments that could make their recovery easier for them?

Did you know that the Medicaid program is an important tool that makes the kind of care you’re imagining a reality?

More than 74 million people, including children, older adults and people with disabilities rely on Medicaid to help them access the care they need to get healthy and stay healthy. But in addition to providing affordable coverage, Medicaid programs across the country are working to actually improve the way care is delivered to the millions of Americans who rely on the program.

Medicaid provides states with the financing and flexibility necessary to adopt innovative solutions that lower health care costs by improving care and making that care more person-centered. From helping older Americans get the support they need to age in their own homes instead of a nursing home to improving how we screen for and treat substance use disorders, Medicaid programs are constantly finding new ways to deliver better, more person-centered care

But the structure and funding that make innovation possible is at risk. The health care bills Republicans have proposed would cut Medicaid funding by billions of dollars and impose permanent cuts and caps on the program. The massive loss of funds would force states to cut costs dramatically and force states to focus on ways to reduce eligibility, benefits and provider payments rather than ways to improve care and lower long-term costs through innovation.

The Republican health care proposal is a step backwards in making the health care system more person-centered. It not only threatens the health coverage of millions and Americans, but would upend all the significant progress Medicaid has made in ensuring patients can get healthy and stay healthy.

The Senate yesterday delayed its plan to vote on its health care repeal bill, also known as the Better Care Reconciliation Act of 2017 (BCRA). On Monday, the Congressional Budget Office (CBO) released its score of the bill and projected it would cause 22 million individuals to be uninsured by 2026, including 15 million individuals enrolled in Medicaid. The bill effectively ends the Medicaid expansion program and cuts $772 billion in Medicaid funding. Senate Republicans offer two options to current expansion enrollees: 1) prohibitively expensive coverage, or 2) no coverage at all.

Spending half their annual income on health care is not a viable option for low-income families

Republican Senators were quick to tout that current Medicaid expansion enrollees still had coverage options under the bill because it expands the eligibility for tax credits to the expansion population (i.e., from 100-400 percent of the Federal Poverty Level (FPL) under the Affordable Care Act (ACA) to 0-350 percent FPL). Senator Richard Burr of North Carolina touted that the bill “better targets tax credits to low-income individuals.”

But the bill’s replacement of Medicaid with private coverage is not a viable alternative for this population. First, the bill cuts tax credit funding by $408 billion, and therefore while it attempts to provide credits to more low-income individuals, there will be substantially less funding to go around. Second, the bill changes the tax credit eligibility rules to prohibit anyone with an offer of employer-sponsored insurance (ESI) to be ineligible for tax credits, regardless of how much that ESI would cost. But Medicaid expansion enrollees’ incomes are so low, that almost any offer of ESI would be prohibitively expensive for them. Yet, under the Senate bill, that coverage would be their only option.

In addition, the Senate bill ties tax credits to plans with far higher out-of-pocket costs, which will make coverage prohibitively expensive for many, particularly those between 0-100 percent FPL. Specifically, the bill changes the “benchmark plan” on which premium tax credit calculations are based from the ACA’s “silver-level” plan – a plan that covers 70 percent of the costs of the standard population – to a plan that only covers 58 percent of such costs, leaving enrollees with significantly higher out-of-pocket costs. The CBO estimates that moving the benchmark plan to a 58 percent Actuarial Value plan would lead to deductibles that would represent a “significantly higher percentage of income” than under the ACA, and individuals at 75 percent FPL would be required to spend more than half of their income on their deductible. As a result,” the CBO concludes, “few low-income people would purchase any plan.”

Unaffordable coverage options will lead to spikes in uncompensated care

If the current Medicaid expansion population chooses not take up either of these highly problematic options, there will likely be a spike in uncompensated care costs that providers and states will have to absorb. Research has shown that states that expanded their Medicaid programs saw significant reductions in their uncompensated care costs, but these reductions will likely reverse under the bill. Instead, left only with the options of employer-sponsored coverage or marketplace coverage, many Medicaid expansion enrollees may simply choose not to enroll in coverage, as the CBO expects, and instead seek care at safety-net providers. And many who do enroll will be burdened with medical debt when they seek care, since they will not be able to afford their deductibles.

Overall, to provide affordable coverage options to low-income individuals, the Senate needs to reverse course entirely. Right now, the basic structure of bill is tax cuts for the rich financed by benefit cuts for low- and moderate-income families. Unless that underlying structure is changed, it’s clear that Medicaid expansion enrollees will be left behind.