The future not so bright for Ryancare in Arkansas

Steve Barnes
House Speaker Paul Ryan of Wis., right, takes his notes as he and House Majority Whip Kevin McCarthy, R-Calif., walk away following a news conference on the American Health Care Act on Capitol Hill in Washington, Tuesday, March 7, 2017.

“I think it’s not going to be good for Arkansas and when it gets to the Senate there will be a lot of pushback.”

The crisp (or terse?) comment by a veteran of four decades in Arkansas health care, some of it in government and the rest in the private sector. It came in an email response to my query about the long-awaited House Republican plan to replace the Affordable Care Act, or Obamacare, if you prefer. But best to clarify: It is the “repeal and replace” plan submitted by Speaker Paul Ryan and his allies. Indeed they are Republicans, but they are not every House Republican; they may not be enough Republicans.

Forget for a moment the Senate: At its unveiling on Tuesday the Ryan program was greeted with screeches and howls emitting from the Speaker’s right flank, not only in the House but in the conservative think tanks and from libertarian billionaires such as the Koch brothers. “Obamacare 2.0” a Koch-funded entity decried it. “A train wreck waiting to happen,” declared the Cato Institute. The Club for Growth (once dubbed “The Club for Greed” by none other than former Gov. Mike Huckabee) slammed it as “Ryancare,” not a compliment.

First District Congressman Rick Crawford declared himself opposed to Ryan’s legislation;  it doesn’t get the job done, the job being burning to cinders Obamacare’s every page. From Arkansas’s two U.S. Senators and its three others representatives: Silence, save for promises to “study” the bill. All of them voted in January for legislation easing the path to Obamacare’s repeal, having in previous years supported abolishing it in what were essentially “show” votes; with its namesake in the Oval Office with his veto pen at hand, the bills were a hollow exercise.

Steve Barnes

Not now, not with their party controlling both the White House and the Congress. And their fellow Republicans controlling both the governor’s office and the General Assembly.

Through its expansion of Medicaid and the subsidies it provided to some beneficiaries, Obamacare extended health insurance coverage to 400,000 Arkansans. Thus it eased the crushing financial pressure of uncompensated care borne by physicians, hospitals and other providers. This pleased them, if not as much as it pleased that 12 or so percent of Arkansans who, many of them, were freed of the even greater burden of going without coverage, or simply obtained services and ignored the bill. It even pleased Gov. Hutchinson, who said he didn’t like it but who persuaded the General Assembly’s ruling Republican majority to continue the Medicaid expansion. It has continued to pump millions into the state’s treasury and its larger economy, permitting them the delight of cutting taxes by some $150 million while balancing the government’s budget.

Ryancare, or Trumpcare, may delight them anew even if their constituents eventually find the proposed changes are less than, well, delightful. Mr. Hutchinson says he has found the President’s health secretary amenable to a cap on enrollment in the Medicaid expansion; restricting participation to those at 100 percent of the federal poverty level, as opposed to 138 percent, would reduce the current caseload by about 20 percent. A big saving for the state. Those 60,000 low- or moderate-income Arkansans, the Governor says, would then rely on federal subsidies in the form of tax credits to cover “most” of their medical insurance premiums.

Two assumptions are at work in Mr. Hutchinson’s scenario. The first is that those pushed off the Medicaid rolls would choose to enter the marketplace, would find it affordable. (Coverage costs for some older Americans under Ryancare could increase five-fold.) The second is that the federal subsidies would continue under any bill the Congress would enact, or be affordable if they do survive.

It is those subsidies, the tax credits, and the Medicaid expansion, among other elements, that are anathema to the hard-liners in the U.S. House.

The Senate? Even more trouble for Ryancare there. Republican members whose states have benefited handsomely from Obamacare, and who have less fear of primary opposition or are less ideologically rigid than their House GOP counterparts, are rather less disposed to embrace the bill. Not even the usually reliable carrot that Ryan & Co. predictably included — defunding Planned Parenthood — was sufficient to enthuse them.

The Ryan plan includes no financial impact statement, no “scoring” by the Congressional Budget Office. But assessments by independent analysts do not bode well for its impact on either federal deficits or these less affluent.

Ryan’s leadership is on the line, not for the first time. Expect Arkansas’s Washington delegates to choose their words carefully.