Editorial: Who wins and who loses in the Senate health bill (as if you can’t guess)

Health care advocates are in the midst of a 24-hour vigil outside of the Trump International Hotel and Tower at Columbus Circle in New York on June 22.
(Andrew Gombert / EPA)

The Senate GOP leadership calls its proposal to overhaul Obamacare the “Better Care” act. But better care for whom?

* Not for the working poor. The bill’s new premium subsidies for those not covered by large employer health plans would be less generous than they are now, pushing recipients into policies with higher deductibles and co-pays. And when the new subsidies begin in 2020, the bill would end the second set of subsidies that the Affordable Care Act provided those near the poverty line to offset their out-of-pocket costs.

* Not for the middle class. Instead of extending help to more middle-income consumers squeezed by higher premiums in the individual market, the bill would extend help to fewer.


* Not for impoverished, childless adults in the 31 states that expanded Medicaid to cover them, as the Affordable Care Act encouraged them to do. The bill would gradually reduce the federal support for these expansions, making it prohibitively expensive for many states to keep insuring this group.

* Not for Medicaid’s traditional beneficiaries — low-income families, the disabled and pregnant women — either. The bill would cap spending in a way that pressures states to cover fewer people with fewer services. On the other hand, the measure does encourage states to improve the quality of care for their Medicaid enrollees — provided that the states cut Medicaid spending even more deeply.

* Not for Americans nearing retirement age who aren’t covered by workplace plans. The bill would allow insurers to shift premium costs from the young to the old, while also reducing subsidies to older consumers of modest means.

* Not for Californians. The measure would ban subsidies from being used on insurance plans that cover abortion, which all policies sold in this state are required by law to do. If the Better Care Reconciliation Act becomes law, the Legislature would have to change that state requirement or Californians would be ineligible for premium subsidies.

* Not for women of child-bearing age, people needing drug treatment or those needing expensive prescription drugs. The bill would let states end the ACA’s requirement that insurance plans cover 10 “essential health benefits” and instead allow insurers to offer less comprehensive (and presumably cheaper) policies. Analysts say that puts coverage for maternity care, substance abuse treatments and costly medications at particular risk.

* Not those who rely on Planned Parenthood for a variety of health services other than abortion. The measure would cut the organization off from the federal funds that help pay for the care it delivers.

Who would benefit from the Better Care act? First and foremost, the measure would bestow hefty tax cuts on high-income Americans and healthcare industry interests. Beyond that, the winners appear to be young, healthy adults, who would be in line for larger subsidies and lower premiums. And if these consumers flocked to buy insurance, that would theoretically hold down premiums for everyone in the individual market. By not requiring much care, they’d help offset the costs of those who do.

Whether any healthy person would actually obtain insurance in the individual market, however, is another question. The Senate bill removes the individual mandate in the ACA — the tax penalty for not carrying insurance — while maintaining the ACA’s requirements that insurers offer policies to everyone and charge the same age-based premium to everyone in a region regardless of their preexisting conditions.

That’s a recipe for markets imploding, as younger, healthier people forgo insurance, knowing that they can sign up for coverage the following year if they get sick or injured. Left mainly with high-cost customers, insurers will raise premiums sharply, leading more healthy people to drop out of the market, prompting more premium increases for the sicker and older people who remain.

We’re seeing a version of that phenomenon already in some states, where problems in the ACA have been compounded by state officials opposed to the law — and now by the Trump administration, which has actively undermined it. The Senate bill would amp up the instability, which is why it includes $50 billion over four years to try to hold the individual insurance markets in each state together.

The bill would throw an additional $62 billion over eight years to states to support other, unspecified efforts to reduce premiums and out-of-pocket costs, stabilize insurers and support doctors, hospitals and other providers. But that’s not a solution; it’s throwing money at a wall to see what sticks.

This is an ugly piece of work, as was the House bill on which it’s based. Worse, it was drafted in secret and is now on a fast track for a floor vote. Its main goal isn’t to improve healthcare in the United States. It’s to lower taxes on the affluent and cut spending, particularly on the poor. It’s not better care; it’s a bitter pill.