When I heard that Mitch McConnell had announced that he would not be seeking a vote in the Senate on the “Better Care and Reconciliation Act of 2017” before the July 4th recess I was upset because McConnell’s move seemed similar to the one Paul Ryan pulled in March that set up a narrow “victory” in early May for the House Republicans’ version of “repeal and replace.” I would have preferred a vote and a definitive loss that might have permanently  settled the issue. McConnell’s move was a strategic response to the devastating analysis rendered by the CBO that advised that more than 20 million Americans would lose their healthcare coverage by 2026.


It is becoming increasingly clear to me that the so called “repeal and replace” process is not so much an attack on “Obamacare” as it is an attempt to greatly reduce what we spend on Medicaid. The New York Times notes that about 40% of all children receive care through Medicaid. Another Times article, “How Medicaid Works,and Who It Covers,” reports that Medicaid pays for the care of more than 74 million Americans including two thirds of nursing home residents, many of whom have middle class families.  In 2013 before the full effect of the ACA more than half the births in America were covered by Medicaid. Beginning January 1, 2014 the ACA offered Medicaid coverage to all Americans earning less than 138% of the poverty level. Even though for most of its 52  years Medicaid has been a nearly equal partnership between the states and the federal government, the federal government promised to cover 100% of the expansion initially and will continue to cover 90% as long as the ACA is the law. The impact of the ACA would have been the coverage of even more lives, but the Supreme Court ruled in 2012 that although the mandate was constitutional, the expansion of Medicaid could be rejected by individual states.


The upside of this moment is that many people who really did not understand the complexity and the components of the ACA are now become appreciative students of the thinking and strategies upon which it was built. They are beginning to understand that its “flaws” are in part the result of the complexity of trying to create a market that blends public and private sources of revenue. Some even understand that the ACA was like a 1.0 piece of software. If our Congress could have approached the problem in a bipartisan way, we would probably be working on ACA 3.0 by now.  As Speaker McConnell would like us to discard the ACA, we are well prepared by the experience we have gained to improve it, but improvement will require more cooperation across the aisle, and more public investment.


Caregivers believe that an investment in improving access to better care is an investment that surely will give a positive return.  Our core problem is the total cost of care. There is a persistent belief among those who understand how complex healthcare is that the path to a lower total medical expense runs through the achievement of universal coverage. If everyone was covered there would be many ways that we could lower the total cost of care. The ACA contained the first step of many of those options.  


Considering the measured good that Medicare has given its recipients, why is there so much resistance to it and why has it become the central focus of the Republican desire to do major surgery on Medicaid as it cans the ACA? Follow the dollars. McConnell’s bill is a proposal to vastly reduce, over a few years, the money available to support Medicaid. It will provide the states with relatively fewer dollars and many governors, even Republican governors, like Baker of Massachusetts, Kasich of Ohio, and Sandoval of Nevada know how devastating this will be for the poor in their states. The Boston Globe published predictions of the impact of the Senate bill on Massachusetts citizens recently released by Governor Charlie Baker. By 2025 the bill would cost Massachusetts 8.2 billion dollars and 264,000 people would lose their coverage.


These governors see past the weak argument that along with fixed funds the bill hands them they will compensate with the new ability to modify their own eligibility rules and localize decisions about what benefits will be covered. They know that the ultimate result will be that their state budgets will be wrecked and hundreds of thousands of their most underserved and poorest citizens will lose the care they need and have come to enjoy.


McConnell and most Republicans have figured out that what middle class voters like about the ACA and are willing to preserve at least the appearance of many of those innovations. They know that the middle class wants to keep their children on their policies until age 26, so that stays in their bill. They also know that the appearance of guaranteed insurability, free of the restrictions of pre-existing illness, is popular so that has stayed in their bills, sort of. The issues with the exchanges is murky. To work financially the exchanges need subsidies to recipients and also to suppliers. There the fix is to remove many of the requirements of good coverage from the ACA’s benefit package and allow older insurees to be charged much more.


To understand the eventual damage to the exchanges listen to the rhetoric of the president and the Tom Price at HHS. They know that they can leave the framework of the exchanges in place but starve them by withholding critical support to the insurers. Tom Price and Donald Trump can reduce support to the exchanges and use other administrative options to continue to damage the ACA without passing anything.  How many times have you heard Ryan, McConnell, Price and Trump predict a “disaster” if we don’t pass their bill?


Many Americans have never understood the necessity of a mandate in establishing an insurance market that does not allow penalties for preexisting conditions and guarantees universal insurability. Doing away with the mandate is doubly beneficial to the political ends of Republicans because it fulfils an ill advised promise to their base, and it allows Ryan to say that many of the people that the CBO says are losing coverage are doing so as a matter of their choice.


As David Brooks has said, Under the Senate bill, deductibles for poor families would be more than half of their annual income.” With a product that offers fewer benefits with deductibles that are stratospheric compared to your income, it is good to be able to chose to pass on coverage, and without a mandate as a fine for not being covered, repeal of the mandate must feel like a new kind of personal freedom that makes sense to the angry, poorer voters who form much of the base that put Trump in office. In the same column, “The G.O.P. Rejects Conservatism,”  Brooks, used a quote from 180 years ago from the writing of Alexis de Tocqueville to show how both Republican politicians and the base that support them have not changed much.


“They owe nothing to any man, they expect nothing from any man; they acquire the habit of always considering themselves as standing alone, and they are apt to imagine that their whole destiny is in their own hands. Thus not only does democracy make every man forget his ancestors, but it hides his descendants and separates his contemporaries from him; it throws him back forever upon himself alone and threatens in the end to confine him entirely within the solitude of his own heart.”


Most of us who are in healthcare understand the benefits that Medicaid has brought to many of our poorest patients and to those who seek to serve them. Many hospitals and practices across the country have seen bad debt decrease and critical revenues that allow doors to stay open rise as a benefit of the expansion of Medicaid under the ACA.  Perhaps many people who see themselves as comfortably ensconced in the middle class don’t really think that reducing federal support for Medicaid will make any difference to them, but they are wrong. I would imagine that taking that 8.2 billion out of the total finance of healthcare in Massachusetts will impact everyone in terms of the premiums and taxes they pay. The rise they will see in their commercial premiums will not be the only bad news. They may be even more surprised and angered when they suddenly realize that the government is no longer paying adequately, or at all, for Mom at the nursing home where she has been for the last year because she can’t take care of herself, has burned through her assets, and all her family members are working.


I feel like I am watching a tragedy. While practicing medicine, I took the benefits that Medicaid offered my organization and my patients for granted. It was socially acceptable to complain about the inadequacy of Medicaid reimbursement, but I am proud to say we accepted what we were given and provided care that was identical to the care our commercial patients enjoyed. We were cost shifting. Now in retirement I participate in the governance of three organizations that serve Medicaid patients and will face substantial challenges if McConnell’s bill is passed. Medicaid dollars are critical to the work of improving our communities and the lives of our most challenged citizens.


An objective of the ACA was to encourage creation of programs that served people to help them to achieve their healthy potential or regain their health. Now the objective is to cut Medicaid and underfund the exchanges so that people earning over $200,000 a year can have a tax cut. Medicaid is a critical support to the institutions that are a critical resource to the objective of


…Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness..


It is ironic that Mr McConnell has called for a pause in the battle to abolish many of the benefits of the ACA and to undermine the role of Medicaid while we observe the Fourth of July.  Like the ACA, America is and has always been an experiment in progress. The experiment got its official beginning on July 4, 1776 when we declared our right to independence so that we could pursue life, liberty, and happiness for everyone. When we wrote our Constitution it was because we realized that our pursuit of a “more perfect union” would require commitment to a set of principles and a government that balanced individual freedom with the power of working collectively. We are a collection of diverse people united in the pursuit of an a ideal that has a paradox at its center. We all deserve the freedom and respect of an individual, but achieve our highest ambitions when we choose as individuals to work collaboratively for the good of the collective seeking to exclude no one.


The journey toward the Triple Aim is one of many examples of an enormous project we have taken on together out of our collective dissatisfaction with an imperfect status quo. It is also an example of the hope that eventually together we will do better. On the Fourth of July as we think about the future it is good to remember that a key part of the pursuit of life, liberty, and happiness requires the good health for all that we can provide if we work together. Failure of the American dream is always a possibility and the possibility becomes a threat when some individuals or group of individuals become self interested in ways that extracts opportunity or excludes and neglects many of their neighbors as would be the case if something like the Better Care and Reconciliation Act of 2017 ever became the law.