Esquire

Repeal and Go Fuck Yourself’ Is in Full Effect

The Graham-Cassidy bill is earning the nickname.

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By Jack Holmes        September 21, 2017

Lindsey Graham has really good healthcare that he definitely won’t lose, even if the moral catastrophe he’s calling a “reform” bill passes the Senate. Graham has cosponsored an Obamacare Repeal and Replace Plan with the impressively mendacious Bill Cassidy and two other Republican heartthrobs. It is somehow worse than the previous plans.

The bill would usher a number of shocking cruelties into law, not least the possibility that as many as 32 million Americans could lose health coverage. That’s 10 percent of the population. We don’t know for sure because Republicans are trying to force the bill through the Senate before its effects can be assessed by the nonpartisan Congressional Budget Office. The bill is full of fun surprises, like the loophole it creates allowing insurers to deny people coverage for a series of basic medical treatments, including:

• Pregnancy and maternity care
• Prescription drugs
• Mental health services
• Reproductive health services, including birth control
• Substance abuse treatment

These were among the 10 “Essential Benefits” that the Affordable Care Act mandated insurance companies had to provide to people who bought their insurance policies. That approach was based on the idea that people’s medical needs might include emergency room visits or prescription drugs, and that insurance companies shouldn’t be able to deny them coverage for things they might actually use. This concept is apparently unacceptable to Republicans—or at least to the donors paying their campaign bills. We can assume Republicans will just wish the millions of Americans suffering in the opioid epidemic the best of luck.

Graham makes his case for the bill.                Getty

Graham-Cassidy opens a very intentional loophole where states can apply for waivers to change the definition within their borders of what constitutes an Essential Benefit. If, say, Mississippi successfully applies to strike pregnancy from the list of Essential Benefits, then insurance companies in Mississippi can refuse to cover some or all procedures involved in pregnancy, or jack up rates on patients who use those services. It would essentially end these protections in states where insurance companies have sufficient influence over state officials.

A host of red states opted out of Obamacare Medicaid expansion after a Supreme Court decision allowed them to. It was free money from the federal government to start, with a relatively small uptick in state contributions down the line. However, it would also have been a win for Barack Obama.

Luckily, the revenge can extend further: Graham-Cassidy is the first Republican plan that would actively punish (primarily Democratically-controlled) states for expanding Medicaid under Obamacare by redistributing some of their funds to red states that refused to expand coverage. This would, according to Graham, “create parity,” even though there could have been parity if Republican governors had simply accepted free money from the federal government to get more of their citizens insured. This could have less than ideal impact for Republicans in future elections, as the states that stand to have their funding shipped off to Texas, Alabama, et al. include Michigan, Ohio, Pennsylvania, and Florida.

The same waiver mechanism could be applied to preexisting conditions. States could apply for waivers to get certain illnesses and medical conditions exempted from pre-existing condition classification. Insurers could then deny coverage to people with those conditions, or jack up their rates. The preexisting conditions provision in Obamacare is based on the concept that people who are already sick may need healthcare, and in America, to get healthcare you need insurance. No need to concern yourself with that any longer.

Let’s give the insurance companies the benefit of the doubt—never a wise decision—and assume they wouldn’t cancel coverage for certain pre-existing conditions, and instead just raise rates on patients who have them. Since Republicans would rather not see a CBO score, we must turn to an outside source: the left-leaning Center for American Progress. As with previous Republican bills, the Center ran estimates on hypothetical premium increases for a 40-year-old with a number of different conditions. Here’s what they found:

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4-grand extra for asthma? It’s a bargain! Just ignore that extra $72,000 if you happen to have brain cancer.

That same waiver mechanism could also be used to circumvent the ACA’s ban on annual and lifetime coverage caps. Soon we could return to the days when an insurance company could arbitrarily cap the amount they’ll pay for your medical care in a year or in your life, regardless of the fact that you did not choose to get, say, a chronic illness like multiple sclerosis. It’s for cases like these that the various Republican bills were so aptly nicknamed “Repeal and Go Fuck Yourself” by the folks at Pod Save America.

Another type of cap the bill fully supports is a cap on Medicaid spending. Graham-Cassidy would end the Obamacare Medicaid expansion program, which currently covers 15 million people, and would pull all childless adults off the program. Instead, the bill will give states a capped block grant for both Medicaid and to substitute for the subsidies provided to people so they can buy plans in Obamacare exchanges. These will be capped at a lower growth rate than scheduled under the current system, and the grants will simply end in 2026, at which point states can either replace federal dollars or roll back coverage. Again, RAGFY.

These Republican bills are aptly nicknamed “Repeal and Go Fuck Yourself.”

One estimate from the left-leaning Commonwealth Fund on Wednesday projected 15 to 18 million would lose insurance by next year, with 32 million off the rolls by 2026. Because Graham-Cassidy will, like the earlier bills, repeal the individual mandate, premiums could spike as much as 15 to 20 percent. Even if these constitute the worst-case scenario, the mediocre case wouldn’t be pretty. It would leave fewer Americans insured, and the ones still on the rolls could be paying more for patchy coverage that might not even have their back when their baby is born.

Actual doctors are almost unanimous in their opposition to this bill. As The Atlantic tells us, it’s very rare for physicians to agree as strongly on anything as they do on the belief that the Graham-Cassidy bill is absolute trash. The bill’s detractors include:

• The American Medical Association
• The American Psychiatric Association
• The American Public Health Association
• The National Institute for Reproductive Health
• The American Academy of Pediatrics
• The Association of American Medical Colleges
• The American College of Obstetricians and Gynecologists
• The Federation of American Hospitals

This is not a comprehensive list. Some of these groups were critical of the Affordable Care Act, but only in regard to certain problems that have emerged with the law. They are all united in forceful opposition to the central goals of the Graham-Cassidy trainwreck.

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So why is Lindsey Graham, a Senate veteran normally known for shoveling money towards defense contractors, putting his neck out on this bill? Why are any of his colleagues giving it a moment’s consideration? It’s hard to say for sure. Certainly, Republicans are desperate to complete the final act of their grand, seven-year-long piece of performance art known as Repeal and Replace Obamacare. Having run on that magic incantation for four straight election cycles, they feel they must deliver for The Base—particularly the members eager to strike Barack Obama’s name from every history book for some reason.

But the real reason this bill has a chance is money. It is not merely the fact that the bill’s savage cuts to health coverage for some of the most vulnerable among us—the youngest, the oldest, the sickest, the poorest—open up billions of dollars of budget savings, which Republicans then plan to use in their grand attempt at tax reform. It’s that the real owners of the party, the donors and the fat cats, have demanded it. At least, that’s the intel The Guardian dug up at a Koch Brothers megadonor conference in June. The “piggy bank” holding a cascade of cash, much of it set to be filtered through dark money operations into Republican campaign coffers and the Super PACs that abet them, are closed until the rich guys get their tax cut.

If reports Thursday morning are anything to go on, Graham doesn’t actually know much in terms of details about his own bill. It’s not as much what he knows as who he knows, however. Not only is Graham very well acquainted with the donors demanding this thing, he’s also BFFs with John McCain, whose dramatic deciding vote spelled death for the previous Senate Republican healthcare bill and etched a truly delicious expression on the face of Mitch McConnell. Perhaps Graham has been enlisted to get his old friend on board. Better get to boarding, Lindsey.