Happy Friday, y’all. Next week looks to be the biggest—or at least most consequential—of the Trump presidency so far, with tens of millions of people’s health care on the line as the Senate moves forward with its health care reform. We’ll talk about that in much greater detail in a second. But first, I wanted to take one last opportunity to plug this week’s Primer sponsor, the Raleigh Flyers, who are playing their final regular season home game tomorrow night. You can click here or on the ad image at the bottom of the page to pick up tickets. —Jeffrey C. Billman

1. THE SENATE’S HEALTH CARE BILL.

THE GIST: Yesterday, after seven years spent criticizing the Affordable Care Act and weeks spent in secret designing their own version of health care reform, Senate Republicans released a draft of the 142-page Better Care Reconciliation Act of 2017. The best way to think about it isn’t as an Obamacare repeal, and definitely not a replacement; it keeps intact many of the basic structures of the Affordable Care Act, from the marketplaces to the subsidies. But rather, think of it as a massive tax cut for the wealthy funded by eviscerating health care for lower-income and middle-class people.. Because—objectively speaking—that’s what it is.

WHAT IT DOES:This New York Times headline pretty accurately sums the bill: “Shifting Dollars from Poor to Rich Is a Key Part of the Senate Health Bill.” Same for this NBC headline: “Trump Wanted ‘Heart.’ He Didn’t Get It.” The BCRA, like the American Health Care Act that passed the House last month, repeals Obamacare’s taxes on the wealthy (it will also give insurance companies a tax break for CEO pay over $500,000); and like the AHCA, it pays for these tax cuts by reducing subsidies to individuals who buy health insurance on the marketplace exchanges and especially by making deep cuts to Medicaid, a program that helps the poor and disabled access health care. But there are some distinct differences between the AHCA and the BCRA that are worth exploring:

  • The Senate’s cuts to Medicaid are more severe than the House’s: to make them more palatable, the changes are phased in over a longer period of time, but the important thing is that the bill caps the amount of money states can get on a per-recipient basis to a level that won’t keep up with medical inflation. That will force states to either raise taxes or cut services.
  • While the House tied insurance tax credits to a person’s age, the Senate will keep the Obamacare model and peg them to income. The Senate will also extend subsidies to low earners who make too much to qualify for Medicaid, which will help in states like North Carolina that declined to expand Medicaid under Obamacare. But it also significantly lowers the income threshold for subsidy eligibility and will force those who qualify for subsidies to pay much more in premiums for health insurance that is far less comprehensive. To be technical, the ACA calculated subsidies based on plans that covered 70 percent of medical expenses; the BCRA bases them on cheaper plans that cover just 58 percent of expenses. These cheaper plans are cheaper because they have much higher deductibles and out-of-pocket expenses.
  • The Senate bill will also end cost-sharing reductions in 2019; CSRs are payments the government makes to subsidize out-of-pocket expenses for lower-income people. As NBC notes, for those who earn 150 percent of the federal poverty line—$36,500 for a family of four—those CSRs reduced the average deductible from $3,609 to $255.
  • The BCRA allows states to waive what are called essential health benefits—things like maternity and mental health care that every insurance policy must cover under the ACA. This will allow insurers to move healthy people into lower-cost plans that cover less, which in turn will make it more difficult for sicker people to find plans they can afford. So while the pre-existing condition mandate will still exist on paper, it will be significantly watered down in practice. The Senate bill will also keep in place the ACA’s prohibition on annual and lifetime caps.
  • The bill cuts off funding for Planned Parenthood and blocks insurance plans on the exchanges from covering abortion (though it’s unlikely this provision will survive).

MEDICAID, BY THE NUMBERS: Because so much of the BCRA is financed by slashing Medicaid to the tune of hundreds of billions of dollars, it’s worth taking a second to look at who Medicaid helps—and who would be hurt by these cuts. In the U.S., Medicaid covers:

  • 20 percent of Americans
  • 49 percent of births
  • 64 percent of nursing home patients
  • 12 percent of adults
  • 40 percent of poor adults
  • 30 percent of adults with disabilities
  • 39 percent of children
  • 76 percent of poor children
  • 60 percent of children with disabilities


MEDICAID IN NORTH CAROLINA:Here, the program covers:

  • 13 percent of residents
  • 35 percent of low-income residents
  • About 40 percent of children
  • About 40 percent of adults with disabilities
  • About 60 percent of nursing home residents

THE POLITICS: Until yesterday, the Senate bill was a closely guarded secret, devised by a dozen or so Republican senators (all men) behind closed doors. There have been no hearings. There will be very limited debate and few amendments. (For those with long enough memories, this is hugely ironic—hypocritical might be a better word—given how these same Republicans railed against the ACA process, which had seemingly endless public hearings and ten months of debate.) Senate Majority Leader Mitch McConnell is planning a vote next week. Right now, it seems, he doesn’t have the votes; yesterday, four conservatives announced their opposition, saying it doesn’t do enough to repeal Obamacare. But their opposition doesn’t seem likely to stick; rather, the smart money is on them folding like a cheap suit.

  • Nut graph, from Politico: “Right now, McConnell is far from having a commitment for the 50 votes needed for passage, according to senators who spoke on condition of anonymity to discuss internal politics of the 52-member caucus. But no one on Capitol Hill seems to be betting against the wily majority leader as he plans for one of the most critical roll call votes of his career next week. ‘He is extremely talented in cobbling together coalitions of people who disagree,” said Sen. Susan Collins (R-Maine), a moderate Republican skeptical of the GOP’s direction. “I never underestimate his ability to pull something off.’”

Even so, it won’t be easy. The AHCA is insanely unpopular, and the Senate’s super-similar version doesn’t seem likely to poll any better. Protesters yesterday staged a die-in outside McConnell’s office, leading to one disabled person being dragged off—the kind of visual the bill’s supporters don’t want. And the bill motivated former President Obama to jump back into the fray in a long Facebook post slamming the health care bill’s “meanness.”

WHAT’S NEXT: In addition to the four conservatives who declared their opposition yesterday, there are some more moderate fence-sitters worried about the impact the Medicaid cuts could have on their state: Shelley Moore Capito of West Virginia, Rob Portman of Ohio, and Dean Heller of Nevada, among them. But it’s one thing to express “concerns”; it’s another to buck the party’s leaders on their biggest legislative priority. Still, a bad score from the Congressional Budget Office could gum up the works. Senate Dems are also planning to avail themselves of every parliamentary tactic possible to slow things down, in hopes of delaying a vote until after the July 4 recess and forcing wavering senators to go home and face their angry constituents first.

Related: While Congress is eviscerating health care for the poor, it also wants to give the Pentagon $100 billion more this year than last year. That’s more than even President Trump asked for.
____________________________________________________________________________________________________________________

2. COOPER HAS THE NCGA BUDGET.

THE GIST: With the N.C. House and Senate both having passed a $23 billion budget, it now rests with Governor Cooper, who has been highly critical of the legislature’s priorities but has not committed to vetoing the budget. The budget provides a 3.3 percent raise for teachers and a $1,000 boost to other state employees, and cuts income and corporate taxes beginning in 2019. It also takes capricious jabs at the attorney general’s office and further hacks away at the governor’s power. Critics, including Cooper, have contended that the bill doesn’t invest enough in schools and infrastructure.

WHAT’S NEXT: Given his public posturing, it’s hard to see how Cooper doesn’t veto the budget. And given the vote counts, it’s hard to see how the legislature doesn’t swiftly override his veto.

Related:The budget ends state-funded retiree benefits for future state employees, including teachers.
____________________________________________________________________________________________________________________

3. SEN. JACKSON SEEKS TO CHANGE CONSENT LAW.

THE GIST: Stories in The Fayetteville Observer and The News & Observer discuss Democratic senator Jeff Jackson’s push to close what he describes as a loophole in North Carolina’s sexual assault law: essentially, in a 1977 case called State v. Way, the N.C. Supreme Court ruled that women could not revoke consent after sexual intercourse begins. Which is appalling and medieval.

  • Money quote: “Legislators are hearing more and more about women who have been raped and are being denied justice because of this crazy loophole. North Carolina is the only state in U.S. where no doesn’t mean no.” —Senator Jeff Jackson.
  • One of those stories: in May, WRAL reported on the case of Amy Guy, whose estranged husband showed up drunk at her apartment in December and demanded sex. Feeling threatened, Guy consented. But when he got violent, she begged him to stop; he wouldn’t. Her husband was initially charged with second-degree rape. But because of State v. Way, WRAL reported, those charges were reduced to misdemeanor assault on the female. He was sentenced to ten months in jail.

CAVEAT: In a lengthy thread, Durham defense attorney/Twitter celebrity T. Greg Doucette argues that the Fayetteville Observer story is “a misreading of a court case interpreting a statute that doesn’t exist anymore.”


WHAT IT MEANS: If Jackson’s interpretation of the statute is correct—I claim no expertise on the question—then this is a loophole that needs fixing yesterday. Even if he’s wrong, though, Senate Bill 553 would seem to my mind a harmless redundancy that simply makes clear that consent can be withdrawn at any time. And if there’s any ambiguity whatsoever, isn’t that a good thing? (Should any lawyers want to tell me how my interpretation is incorrect, I’m all ears: email me at jbillman@indyweek.com.) SB 553 is currently stuck in the Senate’s Rules Committee, where it’s been since April.
____________________________________________________________________________________________________________________

4. THREE LOCAL HEADLINES.

____________________________________________________________________________________________________________________

5. ODDS & ENDS.


Primer this week is sponsored by the Raleigh Flyers, the Triangle’s professional Ultimate Disc team. On Saturday night, they’ll take on the Jacksonville Cannons in their final home game of the regular season. Click the image below to purchase your tickets today.