Friday, September 22, 2017

Graham-Cassidy-Heller-Johnson ("GCHJ") Act versus "America First"

We are living in genuine fear that we will have to move abroad to afford health insurance and medical care. Our own insurance is a private plan already costing over $1,700 a month for two older adults. Applying "GCHJ" to that baseline:

  1. Prior versions of repeal allowed older Americans to be charged 5 times a younger person versus the current 3 times in the ACA. That $1,700 a month would become $2,800 a month.
  2. Pre-existing conditions — and eventually we all have them! — would easily add another 25% to 50% to that, ballooning that $2,800 to as much as $4,000. Unaffordable for working Americans.

Moreover, the prognosis now appears to be even more dire. In reading through the 140 pages of GCHJ, we found that states can apply to have all regulations on health insurance premium rates eliminated. The only thing an insurer can't do is discriminate by sex or "Constitutionally protected class."Given we are still arguing as to what "equal protection" means under the Constitution, this is far more vague and open to interpretation. What is certain is that the ill and those with pre-existing conditions are not constitutionally protected.

What do the authors of GCHJ say about it? From Senator Cassidy's page[1], our numbering, these are bullets on Senator Cassidy's page:

On September 13, 2017, U.S. Senators Lindsey Graham (R-SC), Bill Cassidy (R-LA), Dean Heller (R-NV), Ron Johnson (R-WI) and former U.S. Senator Rick Santorum (R-PA) unveiled legislation to reform health care.

The Graham-Cassidy-Heller-Johnson (GCHJ) proposal repeals the structure and architecture of Obamacare and replaces it with a block grant given annually to states to help individuals pay for health care.

This proposal removes the decisions from Washington and gives states significant latitude over how the dollars are used to best take care of the unique health care needs of the patients in each state.

The block grant is run through CHIP and is subject to a mandatory appropriation.

The grant dollars would replace the federal money currently being spent on Medicaid Expansion, Obamacare tax credits, cost-sharing reduction subsidies and the basic health plan dollars.

The proposal gives states the resources and regulatory flexibility to innovate and create healthcare systems that lower premiums and expand coverage.

More specifically, GCHJ:

  1. Repeals Obamacare Individual and Employer Mandates.
  2. Repeals the Obamacare Medical Device Tax.
  3. Strengthens the ability for states to waive Obamacare regulations.
  4. Returns power to the states and patients by equalizing the treatment between Medicaid Expansion and Non-expansion States through an equitable block grant distribution.
  5. Protects patients with pre-existing medical conditions.

GCHJ also eliminates the inequity of four states receiving 37 percent of Obamacare funds and brings all states to funding parity by 2026. As an example, Pennsylvania has nearly double the population of Massachusetts, but receives 58 percent less Obamacare money than Massachusetts.

Graham-Cassidy-Heller-Johnson treats all Americans the same no matter where they live.

Read more about GCHJ here:

GCHJ Legislative TextGCHJ FAQsGCHJ Section By SectionGCHJ Formula Description

The short version of our assessment is that by repealing employer mandates we are potentially rolling back the clock to the Eisenhower administration. And we hear echoes of 1950's Cold War politics with members of Congress railing against "socialized" medicine.

What's said about GCHJ versus what it does

Republicans continue to insist that each attempt at repeal is an even bigger improvement for Americans, that better health outcomes at lower costs and premiums will be available. It may be that overall per capita health premium expenditures go down because people play Russian roulette with their health. It may be Medicaid per capita expenditures go down because (a) of drastic cuts across the board in Federal contributions and (b) changing Federal funds to per-capita "equitable" block grants, meaning it's no longer a matching funds formula which provides more to states which commit more of their own budget to health care, rather, a state can cut its own funding of Medicaid and still receive Federal Medicaid funds.


Repeal of all mandates

If only people whose houses were on fire at the moment had to buy fire insurance, homeowners as a whole might expend less on premiums, but that would be because many would opt out of insurance while the rest would not be able to afford it. It's that simple. GCHJ will deliver crushing premium increases to the ill and elderly.

The GCHJ also promotes "high deductible" plans (specifically mentioned) with an emphasis on increasing health spending accounts. This will only further wall the ill and elderly into a financially untenable situation with regard to their ongoing medical care.


Repeal of medical device tax

As with the repeal of mandates, this is a another step taken to defund the pool of money available to insurers to cover claims. Yet another means of defunding is to not allow federal re-insurance to step in to protect health insurance providers who suffer losses owing to high rates an costs of claims in areas with endemic health issues. Future denial of this protection, along with threats to not make current subsidy payments not fixed in the Congressional budget, is the primary reason insurers are pulling out of exchanges. In a capitalistic for profit health care industry, you cannot expect health insurance providers to offer policies in areas where they know they will lose money, with no cap on those potential losses. The exit of health care providers in specific counties and states is the consequence of the "free market" and Republican-championed "hands-off," not of ACA regulations.


States can waive (ignore) ACA regulations

States are not obligated to insist on any kind of coverage. Also, any insurance plan offered by anyone anywhere would no longer be qualified for subsidies if it provides abortions outside cases of rape or a health emergency.



"Equitable" = punish states which have put more of their own money into Medicaid programs

This is the most insidious and cynical of all the GCHJ's provisions. How so?

  1. Medicaid expansion is phased out and eliminated, punishing those states, nearly all Democratic, which opted to participate.
  2. Medicaid is changed into a per-capita block grant, rewarding those states which did NOT opt for Medicaid expansion, nearly all Republican. Per-capita granting also effectively ends Medicaid as a "matching-funds" program which rewards those states which apportion more of their own budget to Medicaid for its residents.
  3. Limits on Medicaid will effectively introduce massive cuts over time as costs and population increase.
  4. GCHJ does nothing to address the causes of rising premium and health care costs. The ACA is not to blame for the increasing cost of health insurance premiums. Those were rising even faster rate before the ACA was introduced. And with no guarantee of re-insurance against losses, providers in the health exchanges are being forced to raise their rates further to avoid losses.

This is a massive and vindictive transfer from predominantly Democratic states to predominantly Republican states of a federal Medicaid funding pie that — contrary to numbers which purport to show a rise in funding — shrinks over time on a per-capita basis.

We would add that a state's ability to opt for Medicaid expansion is retroactively terminated as of September 1, 2017.

5. "Protection" of patients with pre-existing conditions

The contention that GCHJ protects those with pre-existing conditions is an outright lie. As we note below, that phrase appears nowhere in the language of the act. By not mentioning pre-existing conditions by name, GCHJ proponents to insist it "does not touch" ACA regulations regarding pre-existing conditions. That is cynical lawyering as the GCHJ allows states to disregard those regulations, opening Americans to a doomsday insurance premium scenario.

Last but not least, and not mentioned in Senator Cassidy's overview, GCHJ introduces an entire set of clauses to insure that Planned Parenthood, and only Planned Parenthood, is singled out for total defunding of all services without having to mention it by name. Planned Parenthood is, for many women, their only lifeline to birth control, maternal, and gynecological care.


  • The word "pre-existing" appears nowhere in GCHJ, and is omitted as a basis for funding in state applications for Federal monies.
  • The phrase "essential benefits," the foundation of the ACA, appears nowhere in GCHJ, also omitted as a basis for funding requests.

That is, the Federal government will take no action to ameliorate the impact of GCHJ deregulation on health insurance premium costs of covering pre-existing conditions or providing comprehensive coverage.

  • All restrictions in rates which can be charged are removed, with the exception that rates cannot discriminate by sex or protected class in the U.S. Constitution. That means any classes protected by Federal law, but not in the Constitution, are not protected.
  • States can opt out of ACA regulations. States which today contribute more to Medicaid have indexed funding taken away, and that is given to states which along political lines did not expand Medicaid.

That is, GCHJ leaves you at the whims and budgetary constraints of the state you live in. And the better your state took care of you in the past, the more likely GCHJ severely impacts its ability to continue to do so.

If you are young and healthy for the moment and willing to play Russian roulette with your health, or you are a business happy to save money and not provide health insurance, then GCHJ is great for you. If you are a state which screwed your disadvantaged by not expanding Medicaid, it's a windfall. If you are among the least densely populated states, you get a bonus. (An obvious ploy for Senator Lisa Murkowski's vote. Alaska is the least densely populated state.)

For the rest, GCHJ is a calamity waiting to be unleashed. GCHJ has absolutely nothing to do with health policy. It is equal parts:

  • Republican on Democratic state retribution not only eliminating Medicaid expansion but redirecting remaining funds to the states that opted NOT to expand Medicaid;
  • an abrogation of Federal responsibility to insure individuals of individual states are not buffeted by political health care dogma having nothing to do with their actual health and welfare, to insure that health care coverage is comprehensive and affordable for every American;
  • a honey pot for the Republican tax cut for the rich, who are demanding payback for their donations and support.

It's difficult to imagine a piece of legislation more reprehensible or punitive to working America. This is an America we cannot imagine and fail to comprehend.

Or given Senator Corey Gardner's behind-closed-doors admonition to his colleagues after the Congressional break that Republican donors are furious — and won't give more until they receive their ACA-repeal-funded tax cuts, we comprehend completely.

FAILS Working America
[1]Bill Cassidy, M.D., United States Senator for Louisiana, accessed 20 September 2017. LINK
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