No wonder Senate Republicans drafted their health care legislation in secret. Beneath the surface, it looks no better than the House version that even President Donald Trump has called mean. This remains a massive tax cut for the wealthy at the expense of the poor, the middle class and the elderly, and it would cost millions of Americans their health insurance. It would be bad for Florida and the nation, and the Senate would be foolish to rush to vote next week on such a cynical, flawed effort to repeal the Affordable Care Act.
The Senate bill is not health care reform. It is health care rationing, forcing many to pay more for less coverage and limiting Medicaid spending in ways that are even crueler than the House bill envisions. It may score slightly better than the House version when the nonpartisan Congressional Budget Office releases its assessment next week, but that will be because of the way the Senate bill's provisions are crafted and timed rather than any epiphany about the importance of accessible, affordable health care.
There are cosmetic improvements in the Senate bill, but don't take them at face value. For example, the Senate would keep roughly the same sorts of tax credits for health coverage available in the Affordable Care Act — but those tax credits would be significantly cut in 2020 and tied to coverage that is less generous. Older people would be hit hardest, and most everyone who buys subsidized coverage now would face significantly higher premiums and higher deductibles. One of the prominent complaints consumers have that they are paying too much for coverage even with subsidies, not that they aren't paying enough.
Another example: The Senate bill appears to be kinder than the House bill to millions of Americans with pre-existing conditions, who cannot be denied coverage under the Affordable Care Act. But in practice, states could have the freedom to eliminate current coverage requirements for all sorts of essential benefits, from maternity care to mental health and substance abuse. States also could kill annual and lifetime limits on out-of-pocket expenses. That means people with pre-existing conditions in states that seek the flexibility — and you can bet Florida would be among the first in line — may find no coverage or coverage that is prohibitively expensive.
This legislation is full of mixed messages. It keeps the Affordable Care Act marketplaces and even provides money to prop them up for a couple of years. Then it undermines the stability of the marketplaces by eliminating the individual mandate to have coverage, which means there would be fewer healthy people to share the risk and rates would have to be even higher. It allows the 31 states that wisely expanded Medicaid to keep getting funding at the same level until 2021 and then continues it at a reduced level for another two years. But the federal money drops so deeply in 2024 that it's unlikely many states would keep Medicaid expansion.
What is unmistakable is the Senate bill's thorough gutting of Medicaid as an entitlement, a long-held Republican goal. It would put a new limit on per person Medicaid spending based on each state's historical spending, and that limit would rise much more slowly than current projections. This would be a disaster in a state like Florida that has been miserly for years. Or states could get a lump sum of federal money to help cover Medicaid costs, which Gov. Rick Scott advocates. But that lump sum would not be nearly enough, and Florida state lawmakers who are allergic to raising taxes would be cutting coverage or further limiting Medicaid enrollment to make ends meet.
The Affordable Care Act has its issues, and it needs more work to lower premiums and deductibles. But it has provided health coverage to more than 1.7 million Floridians and helped thousands more get Medicaid coverage they already were eligible to receive. The Senate bill would make health care less affordable and less accessible. It would cut billions in Medicaid spending and give wealthy Americans billions in tax cuts. The losers would be the poor, the middle-income families and the elderly. Any reasonable Senate Republican, including Sen. Marco Rubio, should reject these untenable tradeoffs and insist on better.