Page 65 of HR 1626, the American Health Care Act: The nearly bill is 128 pages with
very little prose, just references and amendments—changes in wording and
punctuation—to other bills.
Page 65 of HR 1626, the American Health Care Act: The nearly bill is 128 pages with very little prose, just references and amendments—changes in wording and punctuation—to other bills.

Killing Healthcare

by / May. 10, 2017 12am EST

Chris Collins, our Congressional fuckup

Chris Collins represents New York’s 27th Congressional district, which consists of Orleans, Genesee, Wyoming, and Livingston counties, and parts of Erie, Monroe, Niagara, and Ontario counties. He has been getting roasted in the national press because of interviews last week with CNN reporter Wolf Blitzer and Buffalo News reporter Jerry Zremski. 

Blitzer asked Collins if he had read the American Health Care Act—the Republicans’ replacement for the Affordable Care Act, which they always refer to as “Obamacare”— before he voted on it. “I will fully admit, Wolf, that I did not. But I can also assure you my staff did. We have to rely on our staff…I’m very comfortable that we have a solution to the disaster called Obamacare…I’m comfortable that I understand his bill in its entirety, Wolf, without poring through every word.” 

The interview with Zremski put the lie to that brag. When Zremski asked Collins if he was aware that the bill would cut $3 billion from the state’s Essential Health Plan, Collins not only said that he hadn’t noticed that, but he didn’t even know what New York’s Essential Health Plan was. He asked Zremski to explain it to him. “The Essential Plan,” Zremski wrote, in his article on the conversation with Collins, “is an optional program under Obamacare…[that] provides low-cost health insurance to low- and middle-income people who don’t qualify for Medicaid. State Health Department figures show that more than 19,000 people in Erie and Niagara counties were on the Essential Plan in January” (Buffalo News, May 4).

In all, about 58,000 people in Collins’s district and 600,000 low- and middle-income people in New York State will lose coverage or find themselves with significantly higher insurance rates as a result of the bill Collins voted for but did not read.

That led John Oliver, in Sunday’s edition of HBO’s Last Week Tonight, to tell Collins, “Essentially, you fucked up.” Oliver then displayed three graphics saying the same thing.

Collins wasn’t the only one to get pilloried by Oliver Sunday. He also noted that Mark Sanford (R-SC) said he hadn’t read the bill, but he had “turned through every page.” Oliver responded: “That’s not how you read a bill; that’s how you check a bill for spiders. I can’t say that this bill won’t cause millions to lose their insurance, but it does have the Mark Sanders No Spiders guarantee.”

Several other members of the House have admitted they hadn’t read the bill. I suspect that if all 435 members were polled and they answered honestly, most, or even all of them, would make the same confession.

An unreadable bill

Changes were being made to the bill the day before the vote and only three hours were allowed for discussion on the House floor. But that’s not why most members of the House didn’t read it.

Neither is length: It’s only 128 pages, including the title pages and table of contents. It’s got wide margins, 14-point type, a lot of spaces, and only 25 lines per page. An ordinary single-spaced page in 12-point type has 44 lines per page. If the bill were printed the way most office memos are printed, I doubt it would run 50 pages.

The problem is, HR 1626, the American Health Care Act, is unintelligible without a huge amount of specific legislative knowledge, and a huge amount of time chasing down passages in other bills that HR 1626 changes. Even that knowledge and work won’t tell you much unless you are able to figure out the social and economic consequences and implications of those changes.

Some of that information would have been in the Congressional Budget Office report, but the House Republican leadership insisted on having the vote before the report was prepared. 

There is very little straight prose—text that looks like paragraphs—in HR 1626. I think the two longest prose parts have do to with limiting benefits to state lottery winners and denying benefits entirely for birth control, birth control counsel, and abortion. Most of the rest is referential: Clauses name a section in another bill and change a word or phrase. 

That may not sound like much but it is: Think about deleting the word “no” from the First Amendment or the word “not” from the Seventh Commandment.

Had the drafters taken more time, waited for the Congressional Budget Office report on the likely economic effects of the bill, inserted more prose so someone could read the bill and know what all those references were achieving, and permitted amendments, the bill would have been much longer. It also would have been far more intelligible.

I don’t think it is unintelligible by accident or that calling the vote before the CBO report came in resulted from any legislative necessity. 

What the House bill is

HR 1626 isn’t so much a health coverage bill as it is a bill that alters extant health coverage bills and taxes. In general, both the coverage and taxes provided in those other bills are slashed. Since most of the taxes are paid by corporations and rich individuals and most of the coverage is for the middle class and poor, the bill is, at heart, not about health. It is about redistributing wealth. It transfers a huge amount of money from people who have little or none of it to people who have more of it than they can possibly need. 

It could just as legitimately be called the American Wealthfare Act.

What the House bill does

—CBO estimated in March (and that estimate holds for the current bill) 14 million more uninsured by 2018; 21 million in 2020; and 24 million in 2126. 

—The Affordable Care Act provides income-based tax credits and subsidies. Families earning under $20,000 can get tax credits of $3,225 (age 27), $4,123 (age 40) and $9,874 (age 60). That drops for middle income families ($40,000), where the credits are $103, $1,021, and $6,752. There are no credits for families making $75,000 and up. The AHCA provides age-based credits. The effect is, the poor get far less and the well-off get more: $2,000 (age 27), $3,000 (age 40), and $4,000 (age 60).

—A Kaiser Family Foundation study shows that the change in cost of insurance premiums will depend in part on where you live. A 60-year-old in New York in 2020 may see a $1,070 drop in net cost, while a 60-year-old in Nebraska will see a $19,620 increase. Most Americans will incur a significant increase in premiums.

—The bill eliminates most of the taxes imposed by the Affordable Care Act—about $592 billion, almost all of it from individuals with incomes over $200,000, couples with incomes over $250,000, insurance companies, and manufacturers of medical devices.

—The AHCA also makes significant cuts in the Medicaid program, making enrollment more difficult and funding smaller. The CBO estimated in March that would cut about $880 billion from healthcare support to the poor, middle-class, and elderly.

—People with employer-based insurance may also find themselves at risk. Companies may opt for cheaper policies with annual and lifetime benefit limits. Such limits are banned by the Affordable Care Act. States that get waivers would very likely see insurance companies offer many more policy options, some with fewer benefits and lower premiums.

—AHCA provides funding for people with expensive conditions who might be shifted to high-risk pools, but every analysis I’ve seen says that the 10-year allocation of $138 billion isn’t close to enough. People in those pools will be paying a lot more.

The bill does more, but those items give you a taste: less for the poor, less for women, less for elderly; more for the wealthy.

Pre-existing conditions

Pre-existing conditions are protected—but not really.

The bill allows states to get waivers that would let them charge older people five times what they charge younger people for the same protection; eliminate coverage for maternity, mental health, and prescription drugs; and charge more or deny coverage entirely to people with pre-existing conditions. 

A friend posted on Facebook a list of pre-existing conditions: “AIDS/HIV, acid reflux, acne, ADD, addiction, Alzheimer’s/dementia, anemia, aneurysm, angioplasty, anorexia, anxiety, arrhythmia, arthritis, asthma, atrial fibrillation, autism, bariatric surgery, basal cell carcinoma, bipolar disorder, blood clot, breast cancer, bulimia, bypass surgery, celiac disease, cerebral aneurysm, cerebral embolism, cerebral palsy, cerebral thrombosis, cervical cancer, colon cancer, colon polyps, congestive heart failure, COPD, Crohn’s disease, cystic fibrosis, DMD, depression, diabetes, disabilities, Down syndrome, eating disorder, enlarged prostate, epilepsy, glaucoma, gout, heart disease, heart murmur, heartburn, hemophilia, hepatitis C, herpes, high cholesterol, hypertension, hysterectomy, kidney disease, kidney stones, kidney transplant, leukemia, lung cancer, lupus, lymphoma, mental health issues, migraines, MS, muscular dystrophy, narcolepsy, nasal polyps, obesity, OCD, organ transplant, osteoporosis, pacemaker, panic disorder, paralysis, paraplegia, Parkinson’s disease, pregnancy, restless leg syndrome, schizophrenia, seasonal affective disorder, seizures, sickle cell disease, skin cancer, sleep apnea, sleep disorders, stent, stroke, thyroid issues, tooth disease, tuberculosis, and ulcers.”

Are you in there? The list could no doubt be extended to get you. 

The exclusion doesn’t only cover conditions that are real; it covers conditions that are documented. Some physicians enter into patients’ records possible conditions in order to avoid potential lawsuits later because they may have misread or missed symptoms. 

That’s vague, so I’ll give you an example of what I’m writing about: me. 

Twenty years ago, I experienced some discomfort in my chest. A cardiologist sent me in for an angiogram. It showed my coronary arteries were fine. They decided the discomfort resulted from acid reflux. If I’d taken a Tums, the discomfort would have gone away. I’ve never had any heart problems. Several years later, I was at the same cardiologist’s office for a routine stress test. When I looked at the report (I was fine), I saw that it listed as one of my conditions “heart attack.” I said, “I’ve never had a heart attack.” The doctor said, “You’re right. I can take it out of our records, but the insurance company won’t. As far as they’re concerned, you’ve had a heart problem.” When I went to my internist for a semi-annual physical not long ago, I saw it on a list of past conditions. 

So, were I to change insurance companies, I could be denied insurance, or put into a high-risk pool, with vastly higher premium rates, because of that heart attack that never occurred. In the world of insurance, words on paper matter more than facts in time. The dossier rules.

McSally’s amendment

Ian Crouch reported in The New Yorker that the Republican caucus played the theme song from the Rocky films before going out to take part in the three hours allowed for debate on the bill. Then Martha McSally (R-Arizona) called out, “Let’s get this fucking thing done!” 

With that inspirational music (underdog white guy mostly beating on big black guys) and McSally’s battle cry, they sallied forth and passed legislation that would significantly reduce taxes on the wealthiest Americans and remove healthcare benefits from millions of other Americans, most of them women, children, elderly and the poor. Then they went to the White House and partied with Donald Trump.

HR 1626 specifically excludes members of Congress and their staff. After the bill passed, McSally introduced an amendment undoing that, so the exemption no longer exists. It passed 429-0. She immediately posted a Jack Hornerish page about it on her website.

The Republicans didn’t vote for the McSally’s amendment because they wanted to show or pretend they were like everyone else. They voted for it because the ACHA is going to the Senate as a reconciliation bill, which needs only a simple majority—50 votes—to pass. If the exemption for members of Congress were included, the bill would have to be considered by an additional Senate committee, which would move it into the category of bills that need 60 votes to pass. There is no way the Republicans could get eight Democrats to vote for this dog, so it would be DOA.

The McSally amendment is meaningless anyway: Members of Congress receive healthcare from their employer, the federal government. Nothing the individual state do affects federal employees. Nobody in Congress is going to get caught up in that pre-existing conditions villainy. 

What now?

The House bill goes to the Senate. The Republican committee working on changes is composed of 13 men, no women. They say they’ll wait for the CBO report. That report will probably list more harmful consequences than what’s been figured out so far. Perhaps it will include estimates of how many people will die earlier under AHCA than ACA. That wouldn’t play well back home in the next election.

The House bill passed with a vote of 217 to 213. Twenty Republicans voted no. If three more had joined them, the bill would have failed. Several senators have expressed serious concerns about the House bill. With 50 votes in the Senate, Mike Pence gets to break the tie. If three Republicans choke on it, the bill is dead.

If the revised bill passes the Senate, it goes back to the House, where it is voted on again. More questions there. The bill the House passed was pretty much tailored to the very right-wing Freedom Caucus. Will they vote for a bill less punishing than the one they got last week? How hard-nosed are they? Will the softer version likely to come out of the Senate get some of the 20 Republicans who voted no to come back into the fold? Will they be enough to counter the sulking members of the Freedom Caucus?

Should anything come out of the House, Trump will sign it. He desperately needs a legislative win. He has little concern with content. He gets his jollies holding up a page he’s signed in big letters with fat ink.


You can’t read all the reports, listen to all the interviews, try to get a handle on the huge amount of pain, suffering, and death this legislation would cause, and not ask why?

Why would any legislator vote for something like this, then drive up Pennsylvania Avenue and party like someone in a college fraternity on its goofiest day?

Writing it off to them dancing to the music of the medical companies that gave so many of them big campaign checks is too simple. Many medical organizations were vigorously opposed. The checks may be a factor, but I don’t believe it is the determining factor. 

The justification I have heard most the past several days is that it is unfair to force people without medical problems to pay for people who have medical problems. You know: Your stomach cancer is your fault, and a neonate with a birth defect should have worked harder in the womb. 

It is, in other words, a piece of legislation, and a rationale for that legislation, totally lacking empathy. Empathy is the ability to share another person’s emotions, understand another person’s experience. Empathy undergirds art, particularly narrative art and poetry. 

Over the years, I’ve interviewed more than 200 men and women convicted of murder. Only a few of them were people wholly without empathy. They just didn’t care about what they’d done, about the lives they attenuated, the families they’d destroyed. Only a few: I remember every one of them still. They scare me still. They just did not care.

Donald Trump, I think, is a man wholly without empathy. That’s what let him, throughout his business career, ruin small business owners who believed he would pay them for work they had done in his behalf. Donald Trump does not read. Barack Obama said, not long before he left office, one of the reasons he reads novels was they gave him the opportunity to experience someone else’s sensibility, someone else’s point of view, someone else’s feelings. The only reference to someone’s writing I’ve ever heard Donald Trump make is to Oscar Brown’s lyrics for “The Snake,” which he uses to justify his scorn for immigrants.

I suspect Donald Trump’s lack of empathy licensed a similar lack of empathy in the Republicans who voted for this bill. They have a president who has told them, “We’ve got ours, what they don’t have is their problem.” Maybe they thought that way before and were just waiting for a leader to help them let it out. Maybe they’re just following Trump’s lead. They’ll never tell; perhaps they’ll never know. But after the vote, they went to the White House, posed for pictures, and listened to Trump say, “I’m president. Can you believe I’m president? I’m president.” They smiled for the cameras.

The legislation they just passed is now the Senate’s problem. It’s also our problem. They are also our problem. On November 6, 2018, all 435 House seats and 34 Senate seats will be in play. Many of the House seats are so gerrymandered it would take an apocalypse to toss out an incumbent. But remember: This bill passed by only three votes.

Bruce Jackson is SUNY Distinguished Professor and James Agee Professor of American Culture at UB.