The U.S. Senate is fast-tracking a vote on its “health care” bill–more aptly described as a trillion-dollar tax giveaway for the rich, paid for by spending cuts that will cause millions of Americans to lose their health insurance. Older people and those with low incomes, especially people on Medicaid, are at greatest risk of losing access to health care.

Senate leaders are sticking to the plan of having no public hearings on the revised American Health Care Act, no committee markup, and no amendment process. An all-male group of thirteen Republican senators–not including Iowa’s Chuck Grassley or Joni Ernst–are drafting its terms in secret. (UPDATE/CORRECTION: Ernst has been added to the informal working group.) Other Republican senators have only been briefed on progress. Leaders will send the unpublished bill to the Congressional Budget Office, planning to bring the legislation straight to the Senate floor this month, possibly with only 24-48 hours for the public to learn about its provisions before senators vote.

Calls to U.S. Senate and House offices have recently returned to “normal” levels from before President Donald Trump was inaugurated. That needs to change immediately.

A CLOSED PROCESS

The Republican approach to replacing the Affordable Care Act could not be more different from the process through which Democrats adopted the 2010 health care reform law. Grassley was among the Senate Republicans most involved in health care negotiations in 2009. Then Senate Finance Committee Chair Max Baucus made many concessions to Grassley and to other GOP colleagues.

Republicans aren’t allowing Democrats to read the current draft bill, let alone suggest improvements. Timothy Jost wrote for the Health Affairs blog in March,

In considering the Affordable Care Act in 2009 and 2010, the House held 79 hearings over the course of a year, heard from 181 witnesses and accepted 121 amendments. The current House leadership hopes to get the repeal and replacement legislation through the House in three weeks. The Senate adopted the Affordable Care Act only after approximately 100 hearings, roundtables, walkthroughs and other meetings, and after 25 consecutive days in continuous session debating the bill. It is expected that the current House bill will go directly to the floor of the Senate for a vote. Whatever passes the Senate will return for a conference with the House, if it varies from the House bill, and then go to the President for his signature.

GOP leaders are using the budget reconciliation process, which means they will need only 50 votes in the Senate (with Vice President Mike Pence breaking a tie) to pass the legislation–not 60 votes as most bills need to overcome a filibuster.

The American Health Care Act is far from a done deal. A few conservatives may bolt, for instance if the Senate parliamentarian does not allow anti-abortion language to be included. Three or more GOP senators whose states have expanded Medicaid, or have large populations of older people with lower incomes, may do the right thing for their constituents, rather than vote for big planned cuts.

But don’t count on those scenarios materializing. Senate Majority Leader Mitch McConnell will put up a bill immediately after the Congressional Budget Office scores it. He is willing to use every procedural tactic and will warn his caucus that failure is not an option.

As for the few reluctant Republicans, “McConnell is counting on being able to buy their votes relatively cheaply: possibly with a small ‘opioid fund’ and an extra few years before the Medicaid expansion ends in certain states,” according to Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services.

WHAT GRASSLEY AND ERNST HAVE PROMISED ON HEALTH CARE

Based on their voting records, I assume Iowa’s senators will rubber-stamp any Republican health care bill, no matter what the CBO score reveals, no matter how bad the policy would be for Iowa hospitals or vulnerable seniors or people on Medicaid.

However, Grassley and Ernst have claimed details matter to them as they consider a replacement for the Affordable Care Act. Grassley told reporters in March that Senate Republicans would demand changes to the House version of the American Health Care Act:

Of particular concern is the CBO finding that late-middle-aged Americans could see massive spikes in their insurance costs as a result of the bill, Grassley said. That issue will have to be addressed before Senate Republicans can take up the bill.

Around the same time, a form letter from Grassley to Iowans who contacted him about health care reform said the following (emphasis added):

I believe healthcare reform should rest on a few principles.

First, no one should be disqualified from getting insurance for having a pre-existing condition and there should be no annual or lifetime limits or medical underwriting. If you have children under the age of 26, they should be allowed to stay on your insurance.

Second, any healthcare reform plan has to address the rising cost of healthcare. There is nothing in place to address the underlying causes of the high cost of health care – that is, what it costs for a hospital or doctor to purchase and maintain medical equipment, purchase medicines, carry malpractice insurance, and the like. Lowering the costs of things like those I just listed would drive down the cost of health care, emergency room visits, and health insurance premiums.

Third, healthcare reform has to reestablish states as the main regulators of healthcare. All states have different demographics and healthcare needs and reform must begin with the idea that states know what’s best for their constituents.

I believe these are the principles that Congress needs to follow as we reform our healthcare system. The American people deserve a long-term solution that gives them more choice for less cost, and empowers individuals and states to make their own healthcare decisions.

What we know about the Republican health care bill suggests costs will rise sharply, and that allowing states to ask for waivers could bring back the annual and lifetime limits Grassley claims to oppose.

In a May 25 speech on the Senate floor, Grassley highlighted what he called “the Affordable Care Act’s broken promises”:

PROMISE: You were promised your premiums would go down by $2,500 per family.

IN REALITY: Not even close!

In Iowa, premiums increased up to 43%, in just one year! One farmer told me that his insurance went up from $20,000 to $32,000 in one year. He was able to get the premium down to $25,000 but he has a deductible of $15,000.

THE BIGGEST PROMISE: You were promised access to affordable health care – the law is called the Affordable Care Act. That is the most concerning of all, the situation created by Obamacare is far from affordable.

IN REALITY: Premiums in 2017 have doubled for the majority of states using Obamacare exchanges. In three states, premiums have tripled during Obamacare. One Iowan from Pomeroy, Iowa wrote to me and said that she shopped for an Obamacare plan and found that she would have to pay $9,000 out of pocket before her insurance kicks in. She told me she doesn’t know where that money would come from. That is too expensive to use!

For the past seven years, Obamacare has not been working and it will never work for the American people.

Republicans will not accept failure.

We aim for better and that is what guides as we continue our work repealing and replacing this failed law.

The Congressional Budget Office determined premiums will increase substantially under the House-approved version of the American Health Care Act. Health insurance will be out of reach for hundreds of thousands of Iowans.

Ernst committed to a few principles in this press release from January 12 (emphasis added):

WASHINGTON, D.C. – Today the United States Senate took a step toward repealing ObamaCare. The Senate Committee on Health, Education, Labor and Pensions and Senate Committee on Finance will now work on advancing repeal and replace solutions.

U.S. Senator Joni Ernst (R-IA) issued the following statement after voting in support of this measure:

“Throughout my 99 county tour across Iowa, I hear countless stories from Iowans facing premium increases, as well as skyrocketing out of pocket costs like deductibles and copays that they simply cannot afford. Folks have been demanding relief from ObamaCare, and made that clear when they sent me to Washington in 2014, and they reiterated that call in 2016. It’s time to act.

“The action taken by the Senate is a step towards repealing this disastrous health care law. Iowans deserve affordable health care coverage that meets individuals’ and families’ needs, instead of Washington deciding what is needed in your health care plan.

“As we work to repeal and replace this bill, I recognize that it is critical to have a stable transition period in place and to ensure that folks with pre-existing conditions are not denied coverage.

“Moreover, we must provide choice and flexibility, instead of one-size-fits-all mandates and taxes. This can be done by making coverage more portable, allowing folks to buy insurance across state lines, and encouraging small businesses to come together to negotiate health plans.

“Today marked an important step in repairing the damage caused by ObamaCare so we can replace it with affordable, patient-centered solutions.”

The CBO determined that under the American Health Care Act, many people with pre-existing conditions would lose their insurance–not because insurance companies denied coverage, but because premiums would become unaffordable for millions. In addition, tens of thousands of Iowans with pre-existing conditions have benefited from Medicaid expansion and would lose Medicaid under the Republican approach.

After House leaders cancelled the first planned vote on the American Health Care Act in March, Ernst released another statement on the issue.

While the House did not advance a bill today, we all must continue to work together to promote affordable, patient-centered health care solutions that work for Iowans. As with any reform, we must ensure that it is done thoughtfully and carefully. Making sure Iowans have access to affordable coverage is, and will continue to be, my number one priority.

At a central Iowa event last week,

Ernst stated she wishes Congress would fully repeal the Affordable Care Act and figure out a different way forward.

“A lot of us had really good health insurance plans before Obamacare came into place…” Ernst said. “We are in a world of hurt right now and I wish we could go back in time. Unfortunately, we have been handed a really big mess with the Affordable Care Act and, unfortunately, we can only do what the law allows us to do.”

She said she’s unsure how much money is too much money to spend on a person’s life, but said there must be another way forward.

I am seeking comment from the senator on whether the Des Moines Register paraphrased her accurately, and if so, what she meant by too much to spend on a person’s life. Is she open to allowing insurance companies to set annual or lifetime caps on health benefits, so people with cancer or some chronic illnesses will be on their own after racking up $1 million or more in bills?

WHAT YOU CAN DO

During the next three weeks, we need to call our senators in large numbers. Ben Wikler of MoveOn.org is absolutely right: “What you want is for health staffers to be telling their bosses that they’ve spent all day with the phone from freaked-out constituents.” I’ve enclosed below contact information for every Grassley and Ernst office in Iowa.

When you call, “Ask to speak with the staffer who handles health care for the Senator.” For Grassley’s Washington office, call (202) 224-3744 and ask to speak to Karen Summar. Ernst’s phone number in DC is (202) 224-3254. Note: her former lead staffer on health care, Danielle Janowski, no longer works for the senator, a reader was told this morning. A temporary replacement is unable to answer questions about this issue.

For those with time for more than a phone call, the Indivisible Network has produced an excellent guide on planning and executing an office visit and dealing with problems you may encounter. Wikler provides tips for office visits in this thread too.

Speaking directly to Grassley or Ernst is even better. Health care was a hot topic at Grassley’s recent town hall in Greenfield. But like most Republicans in Congress, Iowa’s senators aren’t holding many events this month where constituents will have opportunities to ask questions.

The Indivisible Network advises, “Set up Google alerts, check local newspapers, check the Senator’s Facebook page, and sign up for their eNews alerts” to find other public events where your senator may appear, like a pancake breakfast or county fair. Try to speak with reporters covering such events. Let them know you are concerned about what the Republican health care bill will mean for you or your loved ones.

If you get an evasive answer from Grassley or Ernst, or from one of their staffers during an office visit, don’t be afraid to repeat the question. Press your point and explain why it matters to you. Seven Indivisible activists in central Iowa showed how that’s done during their meeting with Representative David Young (IA-03) in April. Record the encounter if possible.

Every member of Congress receives clippings including letters to the editor that mention them, so consider expressing yourself in that format.

To increase the chance of a newspaper publishing your commentary, keep it short, ideally less than 250 words. Focus on one point: one way the Affordable Care Act has helped you, one way the Republican health care bill would hurt you or your loved ones, or one concerning interaction you’ve had with Grassley, Ernst, or their staffers. Mention one or two facts about the inequity of the tax cuts, the CBO projections about the uninsured, the expected premium hike for older people, or the devastating impact on Medicaid. Don’t try to cram all of the above into one letter.

Quoting promises Grassley or Ernst made this year can also pack a punch in a letter to the editor. For example, Ernst said in March that any health care reform must be “affordable” and “done thoughtfully and carefully.” But the current bill is being negotiated in secret, with no hearings before the Senate votes. We need a thorough, public debate before passing legislation that affects tens of millions of Americans and about one-sixth of the economy.

Some good fodder for letters to the editor can be found in Chelsea Keenan’s recent story for the Cedar Rapids Gazette. She noted that Iowa’s version of Medicaid expansion and other provisions in the Affordable Care Act

helped push down the uninsured rate in Iowa from 10.8 percent before the ACA to 5.9 percent.

This gives Iowa the sixth-lowest uninsured rate in the country, which in turn has led charity-care levels at hospitals to fall severely, hospital leaders said. In addition, the state has brought in an extra $750 million in 2015 in federal funding to help cover those costs.

“It really helped rein in and rationalize the delivery of care by offering coverage and the opportunity to get the right care at the right time,” said Cindy Mann, the keynote speaker of the conference and a partner at Los Angeles-based Manatt, Phelps and Phillips, a nationwide consulting firm. Mann previously was the deputy administrator and director of the Center for Medicaid and CHIP Services within the federal Centers for Medicare and Medicaid Services.

Mann said that, should federal dollars for the expansion population be done away with in 2020 as the proposed legislation calls for, more than 117,000 Iowans would lose coverage within two years — with that number growing to 148,000 by 2025.

“Virtually all of the people who gained coverage would lose their coverage,” she said.

Keenan quoted Kirk Norris, chief executive officer of the Iowa Hospital Association, as saying “the hospital community is very opposed to the American Health Care Act. We don’t want to see a movement to per capita limits on Medicaid […].”

After you’ve contacted your own senators, think about anyone you know (in “real life” or through social media) in one of the states where Republican senators may be persuadable: Tennessee, West Virginia, Louisiana, Maine, Arkansas, Arizona, Colorado, South Carolina, Nevada, Arkansas, or Ohio.

Please share your own ideas in this thread, along with anything newsworthy Senate staffers told you over the phone or by e-mail.

UPDATE: Staff for both senators told one Iowan who called today that they “hadn’t seen the bill yet so couldn’t comment.” That will be the strategy, right up until the secret bill reaches the Senate floor.

Julie Rovner, chief Washington correspondent for Kaiser Health News, commented today on the secrecy surrounding the Republican bill: “I have covered every major health bill in Congress since 1986. Have NEVER seen anything like this.”

SECOND UPDATE: Ernst was among senators who joined President Trump for lunch at the White House on June 13. Her written statement afterwards didn’t tell us anything about where she stands on Medicaid cuts and other key provisions of the Republican bill.

WASHINGTON, D.C. – U.S. Senator Joni Ernst (R-IA) issued the following statement after her meeting at the White House this afternoon on health care reform:

“We had a productive meeting this afternoon, and discussions will continue to take place over health care reform. The reality in Iowa is that continuing the status quo simply isn’t an option because ObamaCare is unsustainable.

“Wellmark Blue Cross/Blue Shield and Aetna have both pulled out of the Iowa individual market altogether, leaving only one statewide carrier. Additionally, news reports indicate that the sole carrier, Medica, is very concerned about its ability to continue to serve Iowans in the individual market. Should they leave too, 72,000 Iowans will be left without an option to purchase health insurance next year, all because of ObamaCare. That’s unacceptable.

“While traveling across Iowa on my 99 county tour, I hear from Iowans who are looking for affordable, and patient-centered health care solutions; their feedback is critical. As with any reform, we must ensure that it is done thoughtfully and carefully, but also with close attention to how it will affect insurance availability in 2018 and beyond.”

JUNE 15 UPDATE: O.Kay Henderson reports on the latest Ernst conference call with reporters:

“Hopefully, we will be able to have a time period where we do receive feedback after the language is released,” she said today during a conference call with Iowa reporters.

Ernst is among the Republicans in the U.S. Senate who’ve been meeting privately to come up with an alternative to the health care bill that passed the U.S. House in April. However, Ernst told reporters there’s no document, yet, to release. […]

“We really have been working on our own thoughts and ideas in the senate, in our informal work group,” Ernst said. “We are making sure that we are representing our constituents in our own home states and find a way that we can best serve those constituents.”

Unlike the House bill, Ernst suggested Senate Republicans are going to try to find a way to make sure Americans don’t lose their insurance policies because of pre-existing conditions. Ernst said Iowans tell her affordability is their number one concern when it comes to health insurance.

Rovner wrote an excellent piece for about the unprecedented secrecy surrounding the Republican health care bill, and about the “steady retreat from transparency” during the decades she has covered health care legislation.

Since 1986, I have chronicled the passage, and repeal, of the Medicare Catastrophic Coverage Act; the fight over former President Bill Clinton’s health proposal; passage of the Medicare prescription-drug bill; and passage of the Affordable Care Act, in addition to a dozen budget reconciliation measures that altered health care, often in fundamental ways.

Despite promises from incoming Democratic and Republican leaders over the past decade to restore the time-honored process, regular order has not returned. In fact, not only has it become increasingly rare, but the legislative process itself has also become ever more truncated, with Congress skipping steps it deemed inconvenient to partisan ends, particularly as leaders have “end run” the committees that are supposed to do the lion’s share of legislative work. […]

In 2009, the creation process for the Affordable Care Act was both open and closed. There were hundreds of hearings and markups that lasted days or—in the case of the Senate Health, Education, Labor and Pensions Committee—months. But the unsuccessful effort by Senate Finance Committee Chairman Max Baucus, a Democrat representing Montana, to bring Republicans into the fold consisted of weeks of closed-door discussions. The Senate bill that would ultimately become the foundation of the ACA was written in Senate Majority Leader Harry Reid’s office before being debated on the Senate floor for almost a month.

Sarah Kliff wrote an excellent commentary for Vox: “I’ve covered Obamacare since day one. I’ve never seen lying and obstruction like this.”

My professional life in 2009 and 2010 was an endless string of Affordable Care Act hearings aired on C-SPAN. I lived in New York at the time. It became a regular ritual to sit down in my cubicle, plug my headphones into my laptop, and listen to an entire day of Senate debate. […]

Senators wanted to talk about the Affordable Care Act and why they believed they needed to pass it. They gave floor speech and after floor speech defending its provisions. Patients had months to lobby their legislators on particular issues that they thought were important. A few months ago I interviewed one woman, for example, who successfully lobbied former Sen. Kent Conrad (D-ND) to add a ban on lifetime limits in health insurance. […]

There isn’t much C-SPAN to watch these days because the Senate is running a remarkably closed process. There are no committee hearings. There are no floor speeches defending the policy provisions of the bill. Senate Majority Mitch McConnell instead has assembled an ad hoc working group to hash out the details of Obamacare repeal in private meetings.

The biggest priority seems to be just passing a bill, regardless of what the bill actually looks like. Tierney Sneed, a reporter for Talking Points Memo, recently asked Sen. Orrin Hatch, who chairs the Senate Finance Committee, whether it was important to get the bill out a few days before the vote, so the public could review its provisions.

His response was telling. “Well, I think we’re not worried so much about that as we are getting it together so we can get a majority to vote for it,” he said.

Senator Orrin Hatch told reporters today that he hasn’t seen the health care bill. Rovner commented, “Sen. Hatch is chair of the Finance Committee, which SHOULD be writing the bill…”

More facts and figures to cite during your conversations with Senate staffers, via the Center on Budget and Policy Priorities.

Overall, nearly 1 in 10 non-elderly people who would have health insurance coverage under current law would lose it as a result of the bill, and the historic gains in coverage achieved since the ACA was enacted in 2010 would be fully reversed. Supplemental data released by CBO show that losses would be widespread across age and income groups.[2] […]

About 3 million children would lose coverage, increasing the uninsured rate for children by about 50 percent.[3]Children would lose coverage mainly because the House bill would cap and cut federal Medicaid funding (including for children) and slash tax credits that help moderate-income families afford coverage in the individual market. But children could also be affected by the House bill’s repeal of the ACA’s Medicaid expansion for low-income adults, which extended coverage to millions of low-income parents. Research has found that extending coverage to parents results in greater participation among eligible but unenrolled children as well.[4]

6.4 million young adults (age 19-29) — about 1 in 8 people in this age group — would lose coverage. Young adults have sometimes been described as the winners under the House bill, because the bill would reduce average individual market premiums for young adults, at least before accounting for tax credits.[5] But in fact, as Table 1 shows, both lower- and middle-income young adults would see large coverage losses, unsurprising given the large coverage gains these groups made under the ACA. While these gains partly reflect the ACA’s provision allowing young adults up to age 26 to remain on their parents’ health insurance plans (which the House bill would maintain), the uninsured rate for adults age 19-29 fell by more than one-third between 2013 and 2015. The ACA’s age 26 provision took effect in 2010, while Medicaid expansion and the ACA’s major individual market reforms took effect in 2014, benefitting millions of young adults.

8.2 million middle-aged people (age 30-49) would lose coverage, increasing their uninsured rate by 84 percent. All of the House bill’s major provisions would affect this group. As a result, where just over 1 in 10 middle-aged adults would be uninsured under current law, about 1 in 5 would be uninsured under the House bill.

5.1 million older adults (age 50-64) would lose coverage.[6] The uninsured rate for this group would more than double, the largest percentage increase for any age group. The disproportionate increase likely reflects the fact that the House bill would allow individual market insurers to charge older people premiums five times higher than younger people’s, while also slashing tax credits for older consumers. The combination means that moderate-income older people in many states would see their out-of-pocket premiums quintuple or more. Millions of older adults have also gained coverage through Medicaid expansion, and older people would be impacted by the House bill’s provision to convert Medicaid to a per capita cap. (See Figure 2.)

Maggie Fox reported for NBC News,

The American Health Care Act, the GOP’s answer to Obamacare, could end up costing the U.S. economy close to 1 million jobs, researchers predicted Wednesday.

The bill, if passed as written by the House of Representatives, would start out boosting jobs and increasing economic output because it would cut taxes, the team at George Washington and The Commonwealth Fund found.

But that would change fast, the experts forecast.

“The AHCA would initially cause a brief spurt of economic growth from tax cuts, which primarily help those with high incomes,” said Leighton Ku, director of the Center for Health Policy Research at the Milken Institute School of Public Health at GW, who led the study team.

“However, cuts in funding for Medicaid and health subsidies then begin to deepen, triggering sharp job losses and broad disruption of state economies in the following years,” Ku added.

“Within a decade, almost a million fewer people would have jobs. The downturn would hit the health care sector and states that expanded Medicaid the hardest.”

Contact list for Senators Ernst and Grassley, compiled by Action Iowa:

JONI ERNST
Facebook – https://www.facebook.com/joniforiowa/
Twitter – @joniernst https://twitter.com/joniernst
Email – www.ernst.senate.gov/public/index.cfm/contact
Fax – Resistbot – Text RESIST to 50409
.
Washington
111 Russell Senate Office Building
Washington, DC 20510
Phone: (202) 224-3254
Fax: (202) 224-9369
.
Des Moines
733 Federal Building
210 Walnut Street
Des Moines, IA 50309
Phone: (515) 284-4574
Fax: (515) 284-4937
.
Davenport
201 West Second Street
Suite 806
Davenport, IA 52801
Phone: (563) 322-0677
Fax: (563) 322-0854
.
Sioux City
194 Federal Building
320 Sixth Street
Sioux City, IA 51101
Phone: (712) 252-1550
Fax: (712) 252-1638
.
Council Bluffs
221 Federal Building
8 South Sixth Street
Council Bluffs, IA 51501
Phone: (712) 352-1167
Fax: (712) 352-0087
.
Cedar Rapids
221 Federal Building
8 South Sixth Street
Council Bluffs, IA 51501
Phone: (319) 365-4504
Fax: (319) 365-4683
.
————————————————————
CHUCK GRASSLEY
Facebook – https://www.facebook.com/grassley/
Twitter – @ChuckGrassley https://twitter.com/ChuckGrassley
Email – https://www.grassley.senate.gov/cons…/questions-and-comments
grassley.senate.gov/contact
Fax – Resistbot – Text RESIST to 50409
.
Washington, D.C.
135 Hart Senate Office Building
Washington, D.C. 20510
(202) 224-3744
Fax: (202) 224-6020
.
Cedar Rapids 111 7th Avenue SE, Box 13
Suite 6800
Cedar Rapids, IA 52401
(319) 363-6832
Fax: (319) 363-7179
.
Council Bluffs
307 Federal Building
8 South 6th Street
Council Bluffs, IA 51501
(712) 322-7103
Fax: (712) 322-7196
.
Davenport
201 West 2nd Street
Suite 720
Davenport, IA 52801
(563) 322-4331
Fax: (563) 322-8552
.
Des Moines 721 Federal Building
210 Walnut Street
Des Moines, IA 50309
(515) 288-1145
Fax: (515) 288-5097
.
Sioux City
120 Federal Building
320 6th Street
Sioux City, IA 51101
Phone: 712-233-1860
Fax: 712-233-1634