Aug 2, 2017

Rep. Martha McSally (AZ-02) has a request to make.

Please forget she ever voted for the Republican health care bill.

That’s going to be very important for her reelection bid in 2018; polling shows people who’ve heard about that vote view her less favorably.

Did you happen to see the two-page letter she sent out defending her vote? If so, she’d like you to forget that, too. Especially the part where she claimed she only had two options – keeping the Affordable Care Act as is, or voting for the AHCA. Now that she’s openly admitting she had a 3rd option all along – working in bipartisan fashion with Democrats – it would be most inconvenient for you to remember she used to pretend otherwise.

If you really want to help her out, just erase it from your mind that she promised to protect people with pre-existing conditions, and then turned around and voted to eliminate those protections. Anyone who remembers that will surely have a tough time trusting her promises now.

Of course, she could make it easier on all of us and send out a new letter, with an honest assessment of the challenges we face in health care, and the steps she could be taking to address them. But at Represent Me AZ, we’re realists. We know if we want to see a letter like that, we’d have to write it ourselves.

So we did.

This, then, is the letter McSally would have written about health care, if she were being straight with us:

“Dear Constituent:

The Affordable Care Act has accomplished a lot in a few years.”

 

In McSally’s actual letter to constituents, she starts off on the right track, correctly identifying two major problems in the pre-ACA time frame: medical bankruptcy and pre-existing conditions. But then she fails to mention the ACA’s remarkable success in dealing with both those issues.

 

Bankruptcies: Bankruptcy filings fell 50% between 2010 and 2016; medical bills had been a leading cause of personal bankruptcy.


Pre-existing conditions: Prior to the ACA, more than a third of people who tried to buy health insurance “had been turned down, charged a higher price, or had a condition excluded from their health plan” due to a pre-existing condition.


The ACA banned this practice; by 2016, the uninsured rate fell to an all-time low of 8.9%.  

 

In Arizona, more than 1 million people (26% of the non-elderly population) have pre-existing conditions that insurance companies would have considered “declinable” prior to the passage of the ACA.

 

The bill McSally voted for (the AHCA) “would make insurance unattainable for many sick people and raise costs for others,” according to the Congressional Budget Office (CBO). They predict it would cause 23 fewer million people to have health care coverage by 2026.   

 

“The Medicaid expansion, in particular, has achieved impressive results.”

 

Bizarrely, in a letter describing the ACA, McSally leaves out any mention of the Medicaid expansion, which is its central component. More than half the insurance coverage gains under the ACA came from Medicaid, which was expanded to include those earning up to 138% of poverty ($27,725 for a family of three).”

 

The positive results in states that chose to expand Medicaid:

 

1) large reductions in their uninsured rates

2) improvements in access to care

3) fewer people going without medical care due to cost

4) significant reductions in unpaid medical bills

5) budget savings, revenue gains and overall economic growth

6) significant job growth,

7) reductions in uncompensated care costs for hospitals and clinics, and
8) “measurable, substantial reductions in mortality.”  

 

Medicaid is popular : 74% of Americans view it favorably (84% of Democrats, 76% of independents, and 61% of Republicans). Only 12% say they want to see a decrease in Medicaid spending (7% of Democrats, 9% of independents, and 22% of Republicans).

 

McSally is in a very small minority. She told the Tucson Weekly she is “not a big fan of Medicaid,” and suggested that “the best way to solve the problem of providing low-income Arizonans with health coverage was to ensure that there were no low-income Arizonans.” (Note: 38% of Arizonans are low-income.)

 

Medicaid is crucially important to Arizona…”

 

In Arizona, more than 500,000 people gained coverage in the first three years after Medicaid was expanded. 25% of the population is covered by Medicaid, and more than half are children; in fact, a majority of Arizona births are funded by Medicaid.

 

Nearly half the patients at community clinics like El Rio pay for their services with Medicaid.

 

Importantly, half of Medicaid spending in Arizona goes toward long-term care for the elderly and disabled; 22% goes to help Medicare beneficiaries pay for Medicare premiums, co-pays, and services not covered by Medicare.

 

“…and very efficiently run.”

 

Arizona’s Medicaid program is “one of the most efficient, lean programs in the country.” Our Medicaid spending is lower than the national average ($5821 per enrollee vs. $7766).

 

“Nevertheless, I voted to slash our Medicaid funding.”

 

The AHCA takes its deepest cuts from Medicaid; it effectively reverses the Medicaid expansion and would remove $834 billion from the program over a decade, resulting in 14 million fewer people enrolled in Medicaid by 2026. By 2036, Medicaid spending would be 35 percent below what’s expected under current law.

 

But cutting Medicaid is unpopular (65% opposed), so McSally never admits to it in her letter; instead, she tries to make it sound as if Medicaid would get more funding (“more control and funding of Medicaid”) and euphemistically describes the slashing of federal funding as “the transition of Medicaid to the states.”

 

In Arizona, federal funding pays for 75% of our Medicaid expenses. In fact, 60% of all the federal funds we receive is for Medicaid. If the Republican health care plan passes, we’re projected to lose $7 billion through 2026. “Raising taxes to replace the money is unlikely in a Republican-controlled state, so Arizona would likely see drastic cuts to services.” There is no way in this scenario to “ensure our most vulnerable get the care they need,” as McSally claims to want. In fact, “individuals at risk to lose health coverage include: 28,900 people fighting cancer, 16,000 battling opioid addiction and 11,000 Arizonans with serious mental illness.”

 

“Even though state and local leaders think it’s a terrible idea.”

 

If the Republican health care plan were really better for states, as McSally claims, then governors would be lining up to support it. In fact, “there has been no visible effort among governors to lobby in support of the legislation,” and “more than half a dozen Republican governors, including several from states with Republican senators, expressed either grave reservations or outright opposition to the bill.”

 

In Arizona, Gov. Doug Ducey has called the AHCA “the largest transfer of risk ever from the federal government to the states,” and complained that it does not cover the “real-world costs of providing care.”

 

Other state and local voices raised in opposition to the Republican health care plan include former Arizona Gov. Jan Brewer; Tucson Mayor Jonathan Rothschild; Tucson Police Chief Chris Magnus ; Pima County Administrator Chuck Huckelberry; Judy Rich, the CEO of Tucson Medical Center; Lisa Soltani, the Medical Director of El Rio Community Health Center; Dr. Daniel Derksen, Director of the Arizona Center for Rural Health ; the Arizona Hospital and Healthcare Association; and the Health System Alliance of Arizona (including Banner Health, Dignity Health, HonorHealth and Tenet Healthcare).

 

“Doctors hate the AHCA, too.”

 

McSally makes the same implication about doctors that she did about local leaders – that they support the bill because it puts them “back in charge.” In fact, the bill has been denounced by multiple physicians’ groups, including:

 

  1. The American Medical Association
  2. The American Academy of Pediatrics
  3. The American Academy of Family Physicians
  4. The American Psychiatric Association
  5. The American Congress of Obstetricians and Gynecologists
  6. The American Osteopathic Association
  7. The American College of Physicians
  8. The American College of Emergency Physicians

 

The AHCA also polls poorly with individual physicians; 66% have a negative impression of the bill (58% “strongly negative”).

 

“Hospital administrators are very worried – and for good reason.”

 

It’s fairly stunning that McSally’s letter barely touches on the issue of uncompensated care  (hospital care which goes unpaid for), given that the problem would be dramatically exacerbated if the AHCA becomes law.

 

The Medicaid expansion significantly reduced uncompensated care costs at hospitals. Safety-net hospitals (with higher percentages of low-income and uninsured patients) saw their uncompensated care costs fall by roughly 40% from 2013 to 2015.  

 

The AHCA jeopardizes the health care coverage of more than 450,000 Arizonans. Uninsured individuals are more likely to delay medical care for treatable conditions until they’re in crisis, and then turn to high-cost emergency care. The result would be higher rates of uncompensated care – as high as 56% over the next decade, by one estimate; that would lead to a projected negative operating income (-6.0%) for hospitals by 2026.

 

That’s obviously unsustainable; Arizona’s hospital association calls it “a threat to the financial future of our industry.” As the Health System Alliance of Arizona points out, “hospitals cannot simply absorb the total cost of uncompensated care – much of this cost will be passed on to those with private insurance coverage…  it will impact all of us through higher insurance costs and lowered access to care.”

 

“But my billionaire, out-of-state donors are insisting that I vote against the interests of my district.”

 

McSally boasts in her letter about the tax cuts in the AHCA, without mentioning that they “overwhelmingly benefit the highest-income Americans.”

 

The largest cuts – $231 billion – are for high-income households. The 400 highest-income taxpayers would get annual tax cuts averaging about $7 million each.

 

McSally has a long list of billionaire donors who would benefit handsomely. Casino magnate Sheldon Adelson and his wife, for instance, gave $20 million dollars to the Congressional Leadership Fund in 2016, which in turn spent hundreds of thousands on McSally’s congressional race against Dr. Matt Heinz.  The AHCA would give the Adelsons a $43.5 million tax cut in 2017.

 

McSally’s donor Ronald Cameron, who gave $1 million to the Congressional Leadership Fund, has promised to fund primary challenges to any Republican lawmaker who votes against the health care bill.

 

Casino magnate Steve Wynn, the finance chairman of the Republican National Committee, will lead the GOP’s fundraising effort for the 2018 midterms. Trump recently dispatched him to express his displeasure with Nevada Sen. Dean Heller when he opposed the Senate health care bill.

 

None of McSally’s billionaire donors live in her district. We can say that with certainty, because there are no billionaires in AZ-02. Yet she voted to prioritize their interests over the 45,000 people in AZ-02 likely to lose insurance coverage if the Republican health care bill becomes law.

 

“I’ve been justifying the changes to Medicaid by complaining about the ACA’s insurance marketplace, but that’s illogical. They’re completely separate programs.”

 

At its core, the AHCA is a massive cut to Medicaid. Notice, though, that McSally never criticizes Medicaid in her constituent letter (except to complain about the taxes that fund it, which is telling). The bulk of her complaints are directed instead toward the ACA’s individual insurance marketplace.

 

These are two separate programs. About 200,000 Arizonans (3% of the population) purchase their coverage through the ACA’s exchange; nearly 2 million are covered through Medicaid. It makes no sense to use problems with one program as a pretext for a massive overhaul of another.

 

“The ACA marketplace has stabilized.”

 

It’s common to hear politicians claim that the individual marketplace is “collapsing,” as McSally does in her letter. Factcheck.org says this claim is “wishful thinking on (Republicans’) part, with little evidence to support it.” It has been refuted by multiple sources, including the CBO; the National Association of Insurance Commissioners; S&P; the Kaiser Family Foundation; the American Academy of Actuaries; and the Trump administration’s own Center for Medicare and Medicaid Services.

 

In Arizona, a senior vice president of Blue Cross Blue Shield, which is on the exchange in most of Arizona’s counties, says that “we are starting to see some signs of stability.” Centene, which provides marketplace coverage in Pima and Maricopa counties, has said that its financial performance there is now “in line with” its strong financial performance in its other ACA marketplaces.

 

“The uncertainty that does exist is largely being caused by the current administration.”

 

“At least 2/3 of the higher premiums next year are due to political uncertainty created by the Trump administration and Congress.” That’s the analysis of actuarial firm Oliver Wyman, which identified two main causes: “The administration is threatening to withhold payments insurers are owed under the law, and also not to enforce the individual mandate.”

 

We’re already seeing this play out: Blue Cross Blue Shield of Tennessee identifies the same two reasons for its 21% rate increase next year. Those aren’t problems caused by the ACA; they’re caused by the Trump administration’s refusal to enforce the ACA.

 

“And the AHCA would create more instability, not less.”

 

McSally claims that after several years under the AHCA, the individual markets would “stabilize and offer more affordable insurance.” This is terribly misleading.

 

According to the CBO, it is true that average gross premiums would drop by about 20 percent in 2026, compared with what we would expect under current law.  But read the fine print: “This would largely be achieved by offering skimpier plans with higher deductibles, and by pricing the old and the sick out of the insurance market.”

McSally might consider that a “stable” market, but the CBO sees it differently: “The agency reports that the bill could destabilize individual insurance markets in some states, leaving unhealthy Americans unable to buy insurance.”

 

“If I really wanted Arizonans to have more choices, there’s a lot I could be doing to make it happen.”

 

In her letter, McSally cites the fact that most of Arizona’s counties have one choice of insurer on the exchange (actually she says they have only one choice of “coverage,” which is not accurate; both of Arizona’s insurers offer varying levels of coverage). She implies that this is a desperate situation, ignoring the fact that employer-sponsored coverage is often similar in this regard: one carrier, and a choice of plans. McSally, for instance, has said she gets her insurance through Tricare, which has just one contractor for the entire Western region (about 20 states); according the their web site, McSally can choose from 2 different plans.

 

In fact, “exchange respondents are as likely to say they are satisfied with their coverage as respondents with employer coverage,” according to a Deloitte survey.

 

That’s not to say we should ignore the serious concerns of those whose needs are not being met; in fact, just the opposite. They’re the ones lighting the path to the reforms that need to happen. If McSally were serious about giving us all more choices on the exchange, for instance, she could be working toward that goal in numerous ways:

  1. She could push to add a federal public option.
  2. She could fight to give Arizonans the right buy into Medicaid (or the VA, or a state employee plan), as was attempted in Nevada.
  3. She could advocate for the state to require its Medicaid providers to offer plans on the exchange, as was done in Nevada.
  4. She could have protected co-op health plans like Arizona’s Meritus, which were undermined by her own party’s attacks on the “risk corridor provision.”
  5. She could have publicly criticized Aetna for exiting the Arizona market for political reasons, even as it was expecting millions in profits on its Arizona business in 2017.
  6. She could have insisted on increasing the ACA’s subsidies, which would bring more customers into the marketplace (and more carriers to serve them).

 

“But I’d rather pass the buck.”

 

Politicians like McSally hope to place the blame for current problems on the previous administration, but the American public isn’t buying what they’re selling: polling shows that 61% say “any problems with the law moving forward are the responsibility of Trump and Republicans in Congress.”

 

Moreover, three quarters of respondents – including 51% of Republicans and 54% of Trump supporters – say that Trump and his administration “should do what they can to make the current health care law work.”

 

Strangely enough, McSally goes into detail in her letter about the kind of work she thinks it would take to ensure the AHCA’s success, including:

 

  1. “multiple pieces of legislation,”
  2. “actions from the executive branch,” and
  3. “continuous monitoring and adjusting.”

 

Which begs the question: why hasn’t she supported any of those same measures to improve the ACA?

Instead, she tells us in her letter how helpless she was to act, pretending that her only options were to accept the ACA as is, or vote the party line. We showed McSally’s letter to Charles Gaba, the health care data expert at ACASignups.net. He gave us a long list of misrepresentations to address, but this one – the claim that she only had two choices – he calls “the biggest lie of all.” “There’s an obvious third choice: work with Democrats to improve the ACA and fix some of the problems it has.”

 

“The ACA’s mandates are protecting millions from losing their health insurance.”

 

There are two mandates in the ACA; the CBO says both are serving to protect the health insurance coverage of millions.

 

The employer mandate in the ACA required businesses with 50 or more full-time employees to offer affordable health insurance coverage to their employees. The CBO estimates that its removal would mean that 7 million fewer people will have insurance coverage through their workplace by 2026.

 

The individual mandate requires most people to have health insurance or pay a penalty. The CBO predicts that its removal would mean 14 million fewer people insured by 2026. There are two reasons:

 

  1. Some people only signed up for insurance because of the mandate, and
  2. “some people would forgo insurance in response to higher premiums.”

 

Why would eliminating the individual mandate cause premiums to go up? Blue Cross Blue Shield of Tennessee explained it well in their recent announcement of a rate hike for 2018: “Without the mandate, some people who don’t have major health care needs will choose not to purchase coverage in 2018. When healthier members leave the risk pool, the costs of care are spread among fewer members. To make up for that shift, we are adding another 7 percent to our average rates.”

 

McSally has two complaints about the mandates, and they contradict each other. First, she says they’re “heavy-handed.” But, as noted above, the employer mandate only applies to businesses with more than 50 employees. There are special supports and tax credits for small businesses, and polling shows that they support the ACA over the bill McSally voted for by a ratio of two-to-one.)  

 

The individual mandate likewise has built-in protections to prevent undue hardship:

 

  1. People who can’t afford insurance coverage (because it would cost more than 8.13% of their income) are exempt from the individual mandate.
  2. People undergoing personal hardship (homelessness, foreclosure, bankruptcy, etc.) are exempt from the individual mandate.
  3. Penalties are pro-rated for people who had coverage for part of the year.
  4. Penalties are capped for large families.

 

The average penalty paid for tax year 2015 was $470. About twice as many people claimed an exemption as paid the penalty (12.7 million vs. 6.5).  We know McSally is aware of those numbers because she brings them up herself in her letter: “…19.2 million Americans… opted to pay a penalty or get a waiver under the ACA…”

 

Notably, the most common exemption is for individuals who have a low income, but live in a state that did not expand Medicaid.

 

Think about that for a moment. McSally is complaining that some people can’t afford insurance without the Medicaid expansion… at the same time she’s defending her vote to defund the Medicaid expansion.

 

McSally’s 2nd criticism of the individual mandate is that it “didn’t work” to convince healthy people to purchase insurance. As we’ve seen, both the CBO and health insurance companies disagree with her, pointing out that many people purchased health insurance to avoid penalties.

 

There is a case to be made that stronger penalties would convince more people to purchase insurance – but if that’s McSally’s position, then she’s arguing for the mandates to become more heavy-handed, not less. She doesn’t get to have it both ways.

 

“The penalties in the AHCA would not be an improvement.”

 

The AHCA eliminates both mandates, and replaces the individual mandate with a different penalty, called a “premium surcharge”; anyone going without insurance for more than two months would pay 30% more for premiums when he signed up again. Insurance experts point out that the surcharge penalizes people for buying insurance, not for going without; “it would, in other words, exacerbate the problem it is trying to mitigate.”

 

In her letter, McSally says she’s opposed to this penalty, too (although she voted for it). She says she has “other ideas” to incentivize the purchase of health insurance, but doesn’t define them. As Charles Gaba points out, any functional insurance program would “have to have some sort of strong incentive to prevent adverse selection/death spirals.” What’s the best way to do that? As a country we’ve been debating that exact question for over a decade, but McSally still doesn’t appear to have an answer.

 

Meanwhile, the Trump administration is working in the opposite direction, trying to reduce the number of people signing up for insurance coverage. It recently cut short the contracts of two companies providing assistance to people enrolling for the first time; the companies had been “focused on the healthy, young adults needed to keep the insurance markets stable and prices down.” The window of time during which people are allowed to enroll has also been cut in half, and the Health and Human Services web site has been “retrofitted into a bulletin board for information critical of the [ACA].” McSally has made no public objection to these attempts to sabotage the exchanges, even as they jeopardize the health care coverage of her constituents who depend on them.

 

“The ACA’s subsidies protect most Arizonans on the exchange from price increases.”

 

About three quarters of Arizonans purchasing marketplace plans receive subsidies to help them do so. When prices rose last year, those subsidies also rose to meet the need.  When taking that into account, the average monthly premium decreased last year (from $120 to $104).

 

“The bill I voted for cuts subsidies by $276 billion.”

 

In Arizona, those cuts would result in an average increase in total out-of-pocket costs of $4300 – but that number would be much higher for older and low-income people.

 

Why? Because the unlike the ACA, AHCA’s subsidies don’t take a person’s income or local costs into account. They’re tied to a person’s age, but with a maximum that ranges from $2,000 to $4,000. So an older person’s subsidy might be twice a younger person’s – but his premiums can now be as much as five times higher. (This is a change from the ACA, which only allowed plans to charge older people three times as much).  “Generally, people who are older, lower-income, or live in high-premium areas (like Alaska and Arizona) receive less financial assistance under the AHCA. Additionally, older people would have higher starting premiums under the AHCA and would therefore pay higher premiums.”

 

The AHCA would also eliminate the special subsidies (called cost-sharing reductions) that help low-income families pay their deductibles.

 

You can compare your anticipated premium and tax credit under both the ACA and the AHCA using this interactive map. Note, however, that the map does not take pre-existing conditions into account. Under the AHCA, people with pre-existing conditions could be charged much more for insurance (more on that below).

 

“The AHCA would reduce or eliminate the ACA’s most important patient protections.”

 

McSally complains that the ACA “dictat[es] exactly what insurance individuals and families can purchase.” It would be more accurate to say that ACA-compliant plans have to meet basic quality standards:

 

  1. They are required to cover 10 essential health benefits, without annual or lifetime caps, including emergency services, hospitalization, maternity and newborn care, mental health care, and prescription drugs.
  2. With regard to those essential benefits, plans can’t charge more in deductibles or co-pays than the out-of-pocket maximum. In 2017, the maximum is $7150 for an individual or twice that for a family (low-income families qualify for lower maximums). After that limit is reached, ACA plans pay 100% of allowed medical costs.
  3. They must cover 60% of covered medical costs, on average (at the Bronze level).  They can, of course, offer more coverage (Silver, Gold or Platinum plans) and catastrophic coverage (for customers under 30).

 

The list of essential health benefits is the foundation for all the other protections, because the other protections only apply to the benefits on the list. Shrink it, as the AHCA allows states to do, and the other protections shrink right along with it:  “If the essential health benefits standards were eliminated entirely, then these protections against catastrophic costs would become literally meaningless since no spending would be subject to the protections.”

 

That’s why McSally’s claim that the AHCA “prohibits lifetime caps on coverage” is not true: the AHCA “would give health insurance plans a way to once again set up lifetime and annual limits. This would be true not just for states that pursued the bill’s waiver, but for the entire country.”

 

Her statement that the AHCA “prohibits men and women from being charged different rates” is also misleading. The AHCA does keep the ACA’s ban on “gender rating” (charging men and women different rates). But insurers could get around that by excluding or charging more for coverage of maternity care, mental health services (used more often by women) and preventive care such as mammograms and pap smears. The CBO says that out-of-pocket costs for maternity care and mental health services could increase by thousands of dollars per year. (Also worth noting: in a possible sign of things to come, the Trump administration recently “removed any mention of women no longer being able to be charged more than men for coverage” from the Health and Human Services web site.)

 

Finally, Politifact rates as mostly false her claim that the AHCA preserves coverage for those with pre-existing conditions. “If the AHCA passes, it would allow for people with pre-existing conditions to be charged more per year for their insurance coverage – possibly to the tune of thousands or even tens of thousands of dollars more per year, some studies have found.”

 

“Some things I criticize about the ACA aren’t even addressed in the AHCA.”

McSally repeats the “mostly false” claim that the ACA cuts $700 billion from Medicare. (She’s been doing that for five years now, since her 2012 campaign.) Politico called it “misleading” and “an exaggeration,” because “the law doesn’t actually cut Medicare.” The ACA reformed Medicare in ways that saved money (and extended Medicare’s sustainability) without cutting benefits.


The AHCA leaves the majority of those ACA Medicare reforms in place, but that didn’t stop McSally from voting for it.

 

McSally also complains about what she calls the “extremely limited networks” of the ACA – but the AHCA leaves the ACA’s regulations on networks untouched. We’ll note here that insurance companies narrow their networks in order to lower costs. McSally appears to be saying that she wants insurance to be more affordable, with wider networks, without acknowledging that those two goals are in conflict – and without offering any practical suggestions of her own as to how to make it work. Once again, she’s trying to have it both ways.

 

“The AHCA would deprive tens of millions of their health care coverage, and the ‘fixes’ I support don’t come close to solving the problem.”

 

After the CBO concluded the original AHCA would cost 24 million Americans their health insurance, Republicans slapped a lot of expensive Band-Aids on it. Altogether, those revisions added more than $200 billion back to the deficit, but the CBO determined they’d reduce the uninsured rate by less than half a percentage point.

 

McSally boasts about a number of these less-than-impressive “improvements” in her letter, including:

 

  1. A temporary delay of just one of the tax cuts for the wealthy in order to lessen the cuts to Medicaid.

    The CBO said the first version of the AHCA would cut Medicaid by $880 billion, and the second by $834 billion. That’s only a 5% difference, not even the $60 billion that McSally claimed in her letter and press releases.
  2. A reserve fund intended to “potentially” assist those aged 50 to 64 in paying the AHCA’s higher premiums. Details are fuzzy on this one: “That fund, however, hasn’t actually been created, depends on the Senate creating it from a tax break, and still might not be enough to make health insurance affordable for this group.”

    McSally claims the fund would have $90 billion, but the CBO was expected to score it between $75 and $85 billion. That wouldn’t shave much off the huge price increases the AHCA would cause: “even if fully $85 billion were reinvested in higher tax credits for older Americans… total costs would still increase by an average of more than $4,000 in 11 states,” including Arizona.
  3. $15 billion set aside (over ten years) to help with maternity care, newborn care, mental illness AND substance abuse.

    This figure is preposterously small when you consider that just the first year of treatment for opioid addiction and related illnesses alone is estimated to cost $14 billion.

    In fact, the Senate’s version of the health care bill set aside $45 billion (over ten years) just for dealing with the opioid crisis, and Sen. Maggie Hassan called that “a drop in the bucket.” Republican Gov. John Kasich of Ohio said it was like “spitting in the ocean.”

    Furthermore, specialists in addiction treatment point out that temporary bursts of funding are not an effective strategy. “Who would invest to build and staff treatment programs for temporary funding?”

    In Arizona, Gov. Doug Ducey has declared the opioid epidemic a “state of emergency”; there are 16,000 adults on Medicaid with opioid addictions who are at risk of losing their access to treatment if the AHCA passes.

    So it’s safe to assume that $15 billion would get used up almost immediately. Then what? If McSally has a Plan B for dealing with the other priorities she listed, she hasn’t shared it with us.

    Regarding maternity care, recall that in Arizona more than half the births are funded by Medicaid. We can see where severe cuts to Medicaid would lead by looking at Texas, which rejected the Medicaid expansion, slashed funding for family planning clinics and eliminated Planned Parenthood from the state: Texas now has the highest maternal mortality rate in the developed world – 5 times higher than California’s.

    Regarding newborn care, recall that in Arizona half the children are covered by Medicaid. The U.S. has one of the highest infant mortality rates among developed countries, but the 31 states that expanded Medicaid coverage (including Arizona) have seen improvements in infant mortality. The AHCA’s $834 billion in cuts to Medicaid would jeopardize that progress.

    Regarding mental health care, the American Psychological Association has expressed strong opposition to the AHCA: “Hundreds of thousands of individuals with a pre-existing mental health or substance use disorder would be priced out of coverage or would find that coverage for the services they need was simply no longer available at any price.”

    In Arizona, the AHCA’s cuts to Medicaid would endanger the coverage of 114,000 people currently accessing behavioral health services, including 11,000 with serious mental illness. They would also threaten the survival of programs like the Pima County Attorney Office’s DTAP (Drug Treatment Alternative to Prison), which has a rolling success rate of 65-70%.

    Police Chief Chris Magnus points out that this is a public safety issue. “The impact is that we are going to have more police calls for service, because if they are not on their medication they are not getting therapy. Whatever is going on in terms of that serious mental illness is going to manifest itself in ways that involve other people, and we’re going to get called.”

    Public defender Joel Feinman points out the local financial impact: “The cuts to Medicaid are actually a bill to American taxpayers in the form of higher criminal justice system costs… nothing is more expensive than prison.”
  4. $23 billion (over 10 years) set aside for a federal high-risk pool to cover people with pre-existing conditions. Conservative estimates predict that a functional high-risk pool would require $15 to $20 billion annually. Others say a more realistic figure would be $33 billion annually.  Once again, the AHCA doesn’t come close to filling the gap in coverage that the AHCA itself creates.

 

“My bill denying AHCA exemptions to members of Congress and their staffs was a sham.”

 

McSally’s bill will not subject members of Congress to the same risks of higher costs and reduced benefits that their constituents might face under the AHCA. That’s because they can buy their insurance through Washington, D.C.’s small-group exchange, which in all likelihood will continue to enforce the ACA’s strong patient protections. As a result, “lawmakers and their staffers could end up with more robust and less expensive coverage than constituents in states that are not as friendly to Obamacare.”

Rep. Ruben Gallego (AZ-07) called McSally out on this hypocrisy the same day the bill passed, tweeting, “Ur bill is a sham. Members buy healthcare through the DC exchange. DC exchange will never have lifetime caps or preexisting condition ban.”

 

U of A law professor David Marcus explains the issue more fully in his Arizona Daily Star op-ed, McSally’s Healthcare Insincerity.

 

“The idea that I’d have more influence over the Senate bill than I did over the House bill never made any sense.”

 

McSally claims in her letter that she was trying to get ideas into the Senate health care bill that she couldn’t get into the AHCA. It’s not clear where she got the impression that she’d have more influence in the Senate than she would in the House. The committee of 13 men writing the Senate bill had a “no girls allowed” policy, famously excluding even female Republican senators with decades of legislative experience; it’s doubtful our two-term representative was any more welcome.

 

And in fact, it’s evident they went in the opposite direction from her stated goals:

 

  1. McSally claims she wants to see “our most vulnerable get the care they need” from Medicaid. But the Senate’s cuts to Medicaid went even deeper than the AHCA’s (by hundreds of billions), and would have caused 600,000 more people to lose coverage.
  2. McSally said, “we need to ensure the tax credits are enough to make insurance affordable.” But the Senate bill cut subsidies more than the AHCA ($424 billion, vs. $276 billion), and would have significantly raised out-of-pocket costs (like deductibles and co-pays).
  3. Additionally, the Senate bill would have allowed states to raise the limit on insurer profit; currently, insurers can’t allocate more than 20% of premium revenue to administration, marketing and profits.
  4. McSally said she disagreed with the amendment to the AHCA that would allow insurance companies to charge people more for their premiums if they’d had a 2-month lapse in coverage. The Senate bill went even farther, denying those people the ability to buy insurance at all for a 6-month waiting period.
  5. The Senate bill also eliminated the $15 billion fund McSally touted that would supposedly have gone toward maternity and newborn care, mental health care, and substance abuse (it did add $45 billion to address the opioid crisis, in an attempt to win over senators from states hit hard by the epidemic).

 

McSally is most likely relieved that her name wasn’t associated with the Senate bill, given that it polled even worse than the AHCA; one survey had it at 12% approval.

 

“I have to navigate the political theater, but I don’t breathe life into it, and I don’t enjoy it. To be frank actually, it drains me more than it fills me. It sucks the life out of me.”

 

That one’s an actual quote, from McSally to a group of bankers she addressed on May 30th. Consider – less than a month after she voted to take health care away from more than 450,000 Arizonans, she was complaining about the impact of politics on her life.

 

Sincerely,

 

Martha McSally

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