United States

The State of Healthcare in the USA

American Baseball Legend Yogi Berra, well known for his storied career with the New York Yankees, as well as his tendency to spout paradoxical witticisms, once famously quipped, “It’s Deja Vu all over again!”.

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Here in the United States, that phrase has been getting a lot of airtime recently. Cable News headlines nowadays usually consist of some permutation of the words “Russia”, “Trump”, “Comey”, and “Investigation”, or, in recent weeks, “Senate”, “Healthcare” and “Key Vote”. And with every new break in either of these stories, some new talking head, making the rounds on the news networks, will comment on this sorry state of affairs– they’ll declare something along the lines of, “As the great Yogi Berra once said, ‘It’s Deja Vu all over again!”, and proceed to chuckle at their own attempt to inject a little bit of topical humor into the discussion. Despite the corny subtext, it’s a relevant point– just look at the state of the healthcare debate in the United States.

Before 2010, this country’s healthcare system was subpar in a lot of ways. Look back to 2008, when half of all personal bankruptcies nationwide were caused by an individual or their family’s inability to pay medical fees. Government programs like Medicaid are designed to prevent this sort of thing from happening, by providing insurance to people below a certain income level. But in many states, vast swathes of people have too high an income to qualify for Medicaid, and not a high enough income to purchase their own insurance. As a result, they’re stuck in a sort of terrifying limbo, where if they get badly sick or injured, their lack of insurance can force them into the position of either going bankrupt or dying. Many parents who are given this choice forego medical treatment, whether for themselves or family members, and face certain death rather than jeopardize their family’s future. Health Insurance companies also discriminate on the basis of pre-existing conditions. If someone already has a medical condition when they apply for health insurance, the insurance company can refuse to provide coverage or force them into a high-risk plan designed for people who will actually use it (ergo, it’s a much more expensive plan).

When my twin sister and I were born prematurely, my sister was born with Gastroesophageal Reflux. Our insurance provider wouldn’t allow her to the rest of our family’s plan– she had a pre-existing condition that was considered “high-risk”, so our parents had to put her on a separate, more expensive plan. This is much more of an issue for parents whose children are born with more permanent conditions, or those who can’t afford to put their newborns on a more expensive plan. Health Insurance Companies also used to put caps on the amount of coverage they were willing to provide, and parents of infants who reached that cap could be forced into the same position as people without insurance– they could face the choice between bankruptcy or the death of their baby.

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These are choices that no parent should be forced to make, especially not in a country like the United States, which definitely has the resources to solve these sorts of problems. In 2009, after a year of negotiations, President Obama passed his signature piece of legislation: the Affordable Care Act. The ACA got rid of coverage caps, and to solve the problem of insurance companies discriminating against patients based on pre-existing conditions, the ACA simply banned that practice altogether. This by itself would have introduced a new problem– people could have started to buy insurance only when they needed it, knowing that they could not be denied coverage. That would have quickly destroyed the Health Insurance Industry, by creating one massive high-risk pool. To solve this, the ACA introduced an Individual Mandate, requiring that people purchase Health Insurance or pay a fine, and an Employer Mandate, requiring businesses to provide Health Insurance to their employees. In theory, by putting more people into the system, the cost of Health Insurance would decrease significantly, and, paired with Medicaid Expansions in each state, it would cover the people who didn’t qualify for Medicaid, but also couldn’t afford to purchase their own coverage. It was a graceful solution, one that had already been put into practice in the state of Massachusetts by Governor Mitt Romney, Obama’s opponent in the 2012 Presidential Election.

Despite all this, Republicans vehemently opposed the bill. No Republican Senators voted for the ACA, which managed to get through Congress because of a filibuster-proof Democratic Supermajority. A group of Republican Attorneys General sued, claiming that the Federal Government could not force people to buy something like insurance; The Supreme Court ruled that in fact, they could, as Congress is endowed by the Constitution with the power to regulate interstate commerce. However, the Court struck down the part of the bill that mandated Medicaid Expansion, which meant that the first problem described above wouldn’t be fixed altogether, and not everybody would gain coverage. Some people (fewer than before, but still far too many) would have to choose between death and bankruptcy. Across the country, solicitors general intentionally obstructed hopeful Obamacare enrollees. In practice, what should have been a graceful solution to a nonpartisan issue was obstructed every step of the way. 

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Because of this, Obamacare never met its full potential. Republicans called the bill a failure, and spent seven years promising to ‘Repeal and Replace’ the bill if only they could take back the White House (I capitalize ‘Repeal and Replace’ because these two words are essentially a slogan that’s been used by Republicans across the country for the past seven years). Now, they have control of the House, the Senate, and the Presidency. I’ve drawn out a timeline below, which illustrates how and when things started to get interesting. You’ll probably realize at some point what prompted the repetitive headlines that made Yogi Berra’s “deja vu all over again” quote so topical.

Plan A, July 18, 2016: Republicans unveil a plan to repeal and replace the Affordable Care Act at the RNC. The plan is a repeal that takes two years (waits until after midterm elections) before going into effect, giving the party more time to come up with a replacement. President Trump later slams the proposal, saying that repeal and replace must occur “within an hour” of each other, and should begin as soon as possible.

Plan B, March 6, 2017: At the insistence of President Trump, Republican Leadership in the House of Representatives introduces the “American Health Care Act”. Two weeks later, after the Congressional Budget Office predicts that it would cost sixteen-million Americans their health insurance, and both conservatives and moderates in the party come out against the bill, it is pulled just before a vote.

Plan C, May 4, 2017: Republicans in the House of Representatives push their bill through, with a 217-213 vote, and the support of zero Democrats. Their plan to repeal and replace the ACA is sent up to the Senate.

Plan D, June 13, 2017: Rather than immediately vote on the American Health Care Act, Senate waits for a CBO score. The score predicts that millions more Americans will lose their coverage, protests ensue, and President Trump calls the bill “mean”, prompting a rewrite.

Plan E, June 27, 2017: After Moderate and Conservative Republicans slam the rewritten bill for various reasons, and another devastating CBO Score is released, Majority Leader Mitch McConnell delays the vote until after the July 4th Recess. Republicans against the bill include Senators Lisa Murkowski, Susan Collins, Rand Paul, Dean Heller, Ron Johnson, Jerry Moran, Shelley Moore Capito, and Rob Portman.

Plan F, July 13, 2017: McConnell delays the procedural vote on a new Healthcare Bill, after Senators Rand Paul and Susan Collins come out against it, and Senator John McCain is expected to be out of town recovering from surgery performed on a blood clot above the eye. Two days later, Republican Senators Mike Lee and Jerry Moran announce their opposition to the bill. McConnell announces that this is the end of the bill.

Plan G, July 17, 2017: President Trump says that he will “just let Obamacare fail”. Later that same day, he announces that the Senate should “just repeal”, and come up with a replacement later. After multiple Republican Senators announce their opposition to the idea, the White House drops the plan.

Plan H, July 25, 2017: Senate Votes to open floor debate on a bill to repeal and replace the Affordable Care Act. Senators Lisa Murkowski and Susan Collins vote against, John McCain, who had just been diagnosed with Glioblastoma, a type of brain cancer, enters the chamber to applause, votes yes. With a 50-50 tie, Vice President Pence comes in to cast the 101st vote, votes yes. Senator McCain gives a rousing speech on Senate Floor about restoring the Senate to its former position as the greatest deliberative body on earth, encouraging a real debate.

The plan I, July 25, 2017: McCain doesn’t get his wish. On the same day, with procedural votes cast, the Senate debates and votes on an amendment called the “Better Care Reconciliation Act”, to repeal and replace Obamacare. 9 Republicans and 48 Democrats vote against it, killing what was left of the bill that made it out of the House of Representatives.

Plan J, July 26, 2017: The day after the failed amendment to fully repeal and replace Obamacare, the Senate debates and votes on an amendment called the “Obamacare Repeal and Reconciliation Act”, which would be a partial repeal of Obamacare. 7 Republicans and 48 Democrats vote against it, killing the amendment.

Plan K, July 28, 2017: Just after midnight, the Senate holds a vote on an amendment that is released just hours before the vote is scheduled to take place. Senators Lisa Murkowski and Susan Collins both vote against it, and it comes down to Senator McCain. If he votes with his party for the amendment, called the Health Care Freedom Act, which is a “skinny repeal” of the Affordable Care Act, it will pass. If he votes against his party and casts a “no” vote, it will fail, leaving the effort to repeal and replace the Affordable Care Act dead in the water. After 15 minutes with Mike Pence in his office, and Donald Trump on the phone, McCain walks out onto the senate floor, and gives a thumbs down, casting a vote against the amendment. There is scattered applause, as well as loud gasps and blank stares by Senators all across the chamber, as McCain returns to his seat.

Plan L? Date Unknown: President Trump uses Twitter to threaten Republican Senators who voted against the bill, calling GOP “total quitters” if they’re giving up. However, Senate Republicans are showing no signs of resuming the health care battle for now, and are returning to business as usual.

Now that you’ve read all that, there’s no way that all of these repeal and replace attempts aren’t all blurred together in your mind. If they aren’t, imagine all of that information being very slowly drawn out over the course of several months, then the last few plans released and voted on all in the span of a few days. Most of the attempts were egged on by the President, given terrible CBO Scores, lacked support from both sides of the Republican Party, and ended up failing or passing because of Senators like McCain, Murkowski, and Collins. Each was different, but only slightly, and they came so quickly after one another that it was hard to keep track, even for the people who were directly involved. Maybe it’s over now, maybe it isn’t. But most signs suggest that Congress is as fatigued with going through this same act over and over again as much as their constituents are. healthcare 3.jpg

Thanks in part to the amount of scrutiny that health care has received in recent months, Obamacare is more popular now than ever. It’s become the status quo, and it looks like it’ll be that way for some time. Republican leaders in both chambers of Congress claim to be moving on, to the issue of tax reform.

In the end, the general sentiments of the public can be expressed by a phrase included in the closing remarks of Senator Tim Kaine, just before Thursday’s “skinny repeal” vote. As midnight approached, and the Democrats’ time for floor debate drew to a close, the Virginia Senator and former VP-candidate stood. In the final minutes of open discussion before yet another vote, on another GOP Health Care Bill, the fourth to be written in secret, the fifth with a devastating CBO Score, the third in as many days, he declared his opinion on this sorry state of affairs– “In the words of the great Yogi Berra, ‘It’s Deja Vu all over again!’”.

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