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Mr. President, this health care bill is still mean

Dylan Matthews is a senior correspondent and head writer for Vox's Future Perfect section and has worked at Vox since 2014. He is particularly interested in global health and pandemic prevention, anti-poverty efforts, economic policy and theory, and conflicts about the right way to do philanthropy.

Publicly, President Donald Trump has been a great defender of Congress's efforts to repeal and replace Obamacare, throwing a massive celebration on May 4 when the House passed its bill. But in private, he told Republican senators that the House bill was "mean," and that they would need to improve it greatly.

Trump has since confirmed he attacked the bill in private, and took a snipe at former President Barack Obama for criticizing repeal efforts in similar terms. “He used my term: 'mean,'" Trump said on Fox & Friends. "That was my term, because I want to see — and I speak from the heart — that’s what I want to see. I want to see a bill with heart."

Well, we have a Senate bill now. Two, in fact: the original version released on Thursday, and the amended version, with new incentives for young, healthy people to remain insured, unveiled on Monday along with a Congressional Budget Office analysis.

And both are them are clearly, unequivocally, mean. The Senate bill will take insurance away from tens of millions of people, make low-income Americans pay more in premiums and deductibles, and institute the biggest cut to Medicaid in American history. People will suffer. Some people will die.

According to the CBO, 22 million fewer people will have health insurance as a result of the Senate bill, in its latest form. And 15 million fewer will have Medicaid coverage, as the program is dramatically shrunk to below even its pre-Obamacare funding levels. Spending on health insurance for low- and moderate-income people will fall by $1 trillion over 10 years, of which $772 billion are cuts to Medicaid alone.

The best evidence we have on the effect of health insurance on human mortality suggests that taking insurance away from 22 million people will lead to more than 26,500 excess deaths every year. That’s, as my colleague Julia Belluz notes, “more than the death tolls from firearm homicides, HIV, and skin cancer in the US each year.” Tens or hundreds of thousands more will face medical bankruptcies, a trend that plummeted in dramatic fashion after Obamacare’s passage.

The Senate bill would make the working poor less economically secure

The cuts to Medicaid will hit people who qualified for the program even before Obamacare. Per-person spending on disabled people, elderly people, parents, and other categories of beneficiaries will be capped. States will have an incentive to shift costs, for example by enrolling more 67-year-olds and fewer 85-year-olds. Many could lose nursing home care, a popular form of optional coverage that would be one of the easiest areas to cut once the caps start straining states' budgets.

States could also choose to accept a flat “block grant,” which would sweep away most coverage requirements and not adjust money for population growth. With the block grant, states could immediately cut back on Medicaid eligibility and make benefits stingier, kicking thousands off the rolls and offering worse health care to those who remained. They wouldn't be required to cover poor parents, and could charge unlimited premiums, deductibles, and copayments. They could impose enrollment caps and waiting lists, and they could cut the range of services provided to poor children.

In the place of Medicaid, poor people will have access to high-deductible insurance. People in states that didn’t expand Medicaid right now have nothing, so any insurance is likely better than no insurance, but it's pretty rough.

Under Obamacare, tax credits were tethered to the cost of plans covering 70 percent of medical expenses. The Better Care Reconciliation Act would reduce that amount to 58 percent. That means higher deductibles, copayments, and other cost-sharing devices to make up for lower premiums than a more generous plan like Medicaid would have.

“Somebody making $20,000 a year could easily see deductibles increase dramatically, from $1,000 … up to … $6,300,” Huffington Post’s Jonathan Cohn notes. In other words, that person could spend nearly one-third of their annual income on health care costs before their insurance chipped in to help cover them. And those currently on the exchanges would also get this worse, less comprehensive coverage.

The Senate bill could hurt mothers, old people, and children with disabilities

Mothers and pregnant women could also be worse off. The Senate and House bills both have provisions letting states waive essential health benefits, a key reform from the Affordable Care Act that required all insurers to cover 10 types of procedures and medical services, including pregnancy, maternity, and newborn care. “This means that plans in the individual market could once again decide not to cover maternity care — like 88 percent of plans did before the Affordable Care Act passed," Vox's Sarah Kliff explains.

Old people would also be victims. Under Obamacare, premiums are capped as a share of income, and the caps don't vary by age. Under the BCRA, the caps would vary by age. While a single person earning three times the poverty line ($35,640) pays no more than 9.69 percent of their income on premiums under Obamacare, under the BCRA the caps would vary from 6.4 percent for people under 30 to 16.2 percent for people over 59.

So for a 60-year-old at 300 percent of the poverty line, the maximum premium would go from $3,442 a year to $5,773, per Vox’s Sarah Kliff. And the plan would be less comprehensive, only being required to cover 58 percent of health costs, not 70 percent.

The Medicaid cuts would also hurt disabled students in schools, many of whom receive services in their school districts from the program. Because of the cuts implied by the per capita cap and block grant provisions, AASA, a group representing school superintendents, is warning that school services for disabled children could be cut back or rationed as a result of the federal Medicaid cuts.

“A per-capita cap, even one that is based on different groups of beneficiaries, will disproportionally harm children’s access to care, including services received at school," AASA’s Sasha Pudelski, along with the National Alliance for Medicaid in Education's John Hill and the National Association of School Psychologists' Kelly Vaillancourt Strobach, said in a statement. "Schools are often the hub of the community, and converting Medicaid’s financing structure to per-capita caps threatens to significantly reduce access to comprehensive health care for children with disabilities and those living in poverty."

The Senate bill is mean. If that’s a problem, Trump should promise to veto it.

This is not a compassionate bill. It’s not a bill that tries seriously to reconcile free market principles with a need to protect sick, poor, and vulnerable Americans. There are plans that would do that — ones that cap medical costs as a share of income but preserve a role for private insurance and make patients have skin in the game. They’re not my preferred policy, but they represent serious conservative attempts to generate universal health coverage.

The Better Care Reconciliation Act that the Senate is weighing is not that kind of plan. It’s full of ad hoc, drastic cuts to health care for the poor and disabled, and promises of higher premiums all around. It would put older and pregnant Americans in particularly vulnerable positions. The only real policy goal it accomplishes is funding a big tax cut for top earners. It’s straightforward redistribution from the poor to the rich.

Trump was correct in describing the House bill as “mean.” The Senate bill is just as mean, and cruel, and callous. If Trump was disturbed by the House bill, he should reject the Senate one now. He should promise to veto any bill that reduces the share of Americans with health coverage, and get to work on a new plan that provides “insurance for everybody” and holds Medicaid harmless, just as he promised during the campaign and transition.

It’s not too late.

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