They have saved the worst for last or next to last or maybe a never-ending nightmare of repeal efforts (Groundhog Day). The salient points of Graham Cassidy are: a shift and reduction of the ACA’s financial resources from the federal government to the states as a time limited block grant; a shift of federal resources from the leader states to the most resistant Southern states that have done little or nothing beyond obstruction; waivers to allow states to disenfranchise and/or insurers to charge higher premiums to those with pre-existing conditions and a per capita cap on the federal match for the Medicaid program. For California, these proposals could not be more damaging. A recent report from the CDC (Centers for Disease Control) found that the uninsured rate in California had fallen from 17% to 7% due to the state’s successful implementation of the ACA. This bill will erase all that progress and do far more extensive damage to states' budget and health care system. Over 30 million Americans would lose their coverage.

I lived in Charlottesville twice. The first time was shortly after my birth; my father was attending University of Virginia Law School and rehabbing from his war injuries incurred after his jeep went over a German land mine in France. Hard to believe, but I have lifetime friends from both my first stay and my second stay in Charlottesville.

We dodged a bullet in the Senate; there is now a moment and opportunity for constructive bipartisan problem solving, so let’s start improving the Affordable Care Act. Here are a few ideas worth considering on how to dramatically improve affordability of coverage and accessibility of care in the Exchanges under the Affordable Care Act (ACA).

President Trump is considering ending federal ACA funding for cost sharing reductions. This ACA funding allows individuals with incomes up to 250% of the federal poverty level to reduce their copays and deductibles in the individual market. It costs about $7 billion annually and helps about 5.7 million Americans. He believes that if the funding was ended, the Health Insurance Exchanges would collapse and Democrats would agree to repeal and replace the Affordable Care Act.

Within this bi-partisan House caucus, there are several points of burgeoning agreement on the future of the Affordable Care Act (ACA): 1) Extend cost sharing reductions. 2) Fund states to reduce individual market premiums through reinsurance or high-risk pools. 3) Eliminate the medical devices tax. 4) Roll back the employer mandate to employers of 500 or more employees. 5) Value and outcome based Medicare reimbursements. 6) Cross state sale of insurance.

The House and Senate need to convene the problem solvers as opposed to the Freedom Caucus bomb throwers and work out the following issues: 1) cost sharing reductions, 2) reinsurance and risk adjustments, 3) care and coverage in rural regions, 4) incentives for cost effective care and 5) the uninsured in the non-expansion states.

The latest CBO analysis concludes that the most recent proposed Senate Amendments will reduce coverage by 22 million Americans, will increase deductibles very dramatically in the individual market and the Exchanges, and will reduce the federal deficit by $420 billion over the next ten years. The key difference from earlier versions is jettisoning the cuts in taxes for high income Americans.

The Senate Parliamentarian has just ruled that key provisions in the Republican efforts to repeal and replace the Affordable Care Act will require 60 votes. The Senate rules require 60 votes to defeat a filibuster. Senate Republicans are trying to dodge that rule by entitling their changes as “Budget Reconciliation”, which they can pass with 51 votes, relying on Vice President Mike Pence to break a 50/50 tie.

President Trump and Republican Senate Majority Leader Mitch McConnell have abandoned “repeal and replace” Obamacare (the Affordable Care Act) and instead embraced a straight-out repeal of Obamacare as requested by President Trump, the House Freedom Caucus and Senators Cruz, Lee and Paul. Their calculation is that this threat will cause Democrats to join forces with them on a repeal and replace alternative. One might ask “what are they smoking?” “Why this crusade against coverage for low, moderate and middle income Americans, why this crusade to deny coverage for sick people?”

The Congressional Budget Office projects that, as compared to current law (ObamaCare), this repeal would increase the numbers of uninsured by 32 million, increase premiums by 100% in the individual markets and cause insurers to leave the individual market, such that 3/4th of nation’s population would have no insurer participating in the individual market.

Most but not all Congressional Republicans want to repeal and replace the Affordable Care Act, but they lack any coherent vision or level of agreement on what the replacement should be and they have been unwilling to share their visions with the American public, the Congressional Budget Office and their Democratic counterparts. So they are tinkering in the dark with a variety of ideas, nearly each one worst than the next as they try to bring the two wings of their party together on a jury rigged bill for which they hope to get 50 votes. 

Medi-Cal covers about 14 million Californians and costs about $90 billion. It covers about a third of all Californians, pays for nearly 70% of all nursing home residents and pays for over half of all births in California. About 5.5 million children depend on its coverage. Enrollment in the program has grown from just under 8 million at the end of 2013 to about 14 million today. In California’s rural communities, Medi-Cal is the most important payer, accounting for coverage for nearly half of area residents and key to the financial stability of local hospitals, clinics and doctor’s offices.

Single payer health care in essence means Medicare for All, but with improvements to eliminate all copays and deductibles and to add long term care benefits. There has been fury about the Assembly Speaker’s decision to take a pause and ask the proponents to figure out the financing. In my opinion, this is totally warranted and in fact overdue.