This past week, after hundreds of marches and rallies, after thousands of raucous Town Halls, and after millions of post cards, letters, phone calls and personal contact by millions of concerned Americans across the nation – in Red and Blue States alike, their efforts were rewarded with the implosion of “Trumpcare”, “Ryancare”, or more generally, the Republican Health Care repeal and replace legislation.  Broadly opposed by every medical association – doctors, nurses, hospitals, and other health care providers, by AARP and other senior groups, by child advocates, and by the 20+ million who would lose their health care had the bill been passed by the House Republicans, the proposal went down in flames last Thursday and Friday.  The current aftermath features finger-pointing and blame casting on many of the players.  These includes failures by House Republican Leaders, especially Speaker Paul Ryan; unhelpful comments from some Senate Republicans that undermined the House debate; a number of Republican Governors who wanted to protect their residents on Medicaid against being set adrift by the proposal in 2018; the 35+ House members of the “Freedom Caucus” – ultra-conservatives who insisted on removing “essential protections” that are provided under the ACA; Trump and his advisors who agreed to strip basic “essential” protections from the health care system to appeal to the Freedom Caucus votes and lost more reasonable, centrist, and moderate Republican House members. Republican moderate voices lost in abandoning “essential care” elements were ALL FIVE NJ Republican House members, including the Chairman of the House Appropriations Committee, Rodney Freylinghuysen, occupying an important leadership position appointed by Speaker Ryan.

In my view, this legislation was fatally flawed from the start. Another version of the Ryan ACA repeal that the House Republicans voted for and ran on in several elections, this bill removed health care coverage from more than 24,000,000 Americans – first 14,000,000 right away in 2017 and, thanks to yet another amendment, another 12,000,000 in 2018-2020.  In addition, older adults would see their premiums increase from $1700 a year to 12,000 or more a year according to the Congressional Budget Office (CBO) – an age penalty; an $800 billion cost-shift to the states in Medicaid coupled with reduced funding support and a cap on any subsequent cost-growth, and the loss of health coverage by 24,000,000 Americans presently covered under the ACA.  States that had not joined in the ACA through expanded Medicaid coverage would be barred from adding coverage for those not yet signed on for care, leaving them permanently in a fiscal crises and with hospitals awash in red ink.  Yes…. the legislation would save federal tax dollars…. and be given back to insurance companies and the uber wealthy.  That is a far cry from what candidate Trump promised over and over again during the election campaign.  He assured the American people that he would “replace Obamacare with a new beautiful system of health care that would cover everybody with better service and at lower cost.  You will love it.  Believe me.” Evidently, many American voters did just that – they believed candidate Trump.  And, last week, the man behind the curtain was revealed to be a liar as he turned his back on millions who took him at his word. HYPOCRISY! For now, the ACA remains in place.  But, round two will arrive at some point.  The clock ticks.

Hippocrates, generally referred to as being the “father of modern medicine” and the author of the “Hippocratic Oath” taken by physicians, lived and worked in Greece in 400BC.  One of his most famous statements and one that is included in the modern Hippocratic Oath is a pledge that all doctors take – “FIRST, DO NO HARM.”  Perhaps the Republican Members of Congress should have had that oath in mind as they crafted ACA replacement legislation.  The evidence, however, suggests that the only thing that they had in mind was a massive cost shift to the states and a massive tax cut for the wealthy and profits for the insurance companies.  To give money away, you first have to generate some, in this case, from program savings.  And, that’s why the Freedom Caucus right-wingers, with Trump and Ryan’s support, insisted on “amendments” to the bill as introduced.  I mention them here on the chance that the proposal sank so rapidly last Friday, that their willingness to inflict pain on people and, especially on those who have the least and are least able to defend themselves, have no lobbyists on the Hill, and do not make massive campaign contributions, for the ability to give massive tax cuts to high income earners, large corporations, and to boost the profits of health insurance companies like Aetna, Humana, and BC/BS. (Incidentally, these three insurers’ most recent financial statements reveal that they each claim PROFITS of more than $1 billion a year after taxes under the current ACA system.  Can you say, not collapsing?).

“First, do no harm… .”  Hippocrates would have his hair on fire if he observed the pain that the House Republicans were willing to inflict on the public to enrich the already rich.  They did this through a proposed cost-shift of billions of dollars to the states, bumping millions of Americans off of Medicaid, dramatically increasing insurance costs for seniors and older Americans, and abandoning millions of other Americans by permitting prices to rise beyond their ability to pay and/or eliminating “10 essential health services” from coverage under their health plan. So, here are the ten (10) “essential benefits” presently being required under the ACA that would be eliminated as a requirement and become a “choice of coverage” under Trumpcare/Ryancare:

1. Outpatient care – your typical doctor’s office visit with physicians “in network.”

2. Emergency Room Trips – this includes ER visits and ambulance service.

3. In-hospital care – all care that you receive as an in-patient, including surgery.

   4. Pregnancy, maternity, and newborn care – before the ACA 63% of non-employees coverage
       did not have any maternity benefit, exposing a patient to potentially tens of thousands of
       out-of-pocket expenses.
   5. Mental health and substance abuse disorder services – With the growing threat of opium
       abuse, such coverage is an essential element of a multi-phase approach to a solution.
   6. Prescription drugs – Insurance companies often negotiate group discounts for
       medications.  Left on their own, an individual would be exposed to thousands of dollars of
       avoidable expense.
   7. Rehabilitative services – this includes physical therapy as well as treatments to help those
       with CP, MS, and kids with autism.
   8.  Lab tests – What with rising malpractice insurance costs, doctors often order a full battery of
        tests to be thorough and accurate in making a diagnosis and crafting a treatment plan. Tests
        like bloodwork, xrays, MRI or Cat Scans carry high costs that can be out of reach for
        average working families.
   9. Preventive services – This includes vaccines, cancer screenings, mammograms,
       colonoscopies, and other diagnostic tools commonly used to diagnosis a potential problem
       early on while it is more treatable, curable, less costly, and less lethal.
10.  Pediatric services – including dental and vision care for children.
Most employer health insurance plans already include these benefits as a matter of course. In fact, fewer than 10% of Americans buy their health insurance on the individual market.  The ACA program REQUIRES that all of these be included in a standard health coverage plan.  The Freedom Caucus, and the amended Republican Health Care Plan, eliminates those requirements and, as a result, exposes those insured to a roll of the medical dice.  And, if they “crap out”, leaves the patient, their family, the hospital, and the states in a potentially untenable financial position.  In fact, 57% of US bankruptcy filings list medical bills as the root cause of the financial failure experienced.  Insurance is intended to avoid such pain.  But, not if the insured, because they cannot afford  “Cadillac” plan, have a bare-bones plan that essentially covers very little, resulting in fewer cash outlays by insurance companies, and higher profits for them.
Let’s take auto insurance, for example. Most states require that every driver with a registered vehicle have liability auto insurance in case of an auto accident.  Coverage – liability and comprehensive – is a system of joint risk.  That is, if you have an accident, you are covered.  But, you cannot buy insurance right after you have a crash!  If you could, it would cost whatever the damage total is – say, $40,000, the resulting medical bills if any – say, $20,000, plus 10% administrative fees and another 20% for insurance company profit.  Altogether, that policy would cost you $$78,000!  Not quite affordable…..
If you don’t have a crash, you still have to pay the premiums – no refunds!  So, what happens to your money when you didn’t have a claim?  The pooled money goes to where it is needed – those who had the misfortune of having an accident.  That is what shared risk and insurance is all about. Its the same with health insurance.  Those without accidents pitch in for those with accidents on the promise that should they have a need for help in the future, everyone else would be there.  And, that’s what the basis of insurance is all about.  It’s called “shared risk.”  The ACA set up shared risk in health care, and includes “essential health care” elements so that everyone is covered for those standard services, regardless of having an instant need for specific care.  And, also confident that, sooner or later – whether it be lab tests, surgeries, ER visits, ambulance services, or pharmacy needs, all of us will be able to call upon insurance coverage – rather than the bankruptcy courts to help us through a medical crises.

Republicans, and especially the Freedom Caucus – along with Trump and his senior staff – have demonstrated that they care little for the well-being of working and Middle Class Americans and that their entire agenda is driven by reducing taxes on thee wealthy, large corporations, Wall Street traders and firms like Goldman Sachs, and dismantling the protections hard won over the years for our safety (OSHA), the environment (EPA), consumer protection (FDA), and, in this case, health care for those in greatest need and of modest income.  This is not “fake news.”  Just a simple fact.