The author, sans feeding tubes.
The author, sans feeding tubes. Matthew Cortland

After half a dozen failed proposals to repeal the Affordable Care Act (ACA)—along with hundreds of protests, tens of thousands of phone calls, and after personally yelling at Mitch McConnell over a loudspeaker from the lawn of the Capitol—we’re right back where we started. Graham-Cassidy, as the GOP’s newly proposed ACA replacement is known, would gut Medicaid, eviscerate protections for people with pre-existing conditions, and cause millions of Americans to lose their health insurance. Including me.

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I am alive because of Medicaid. I happen to have a particularly severe and treatment-resistant course of inflammatory bowel disease; because of this, my immune system doesn’t know my small intestine is something it should not attack. During a particularly bad night in the ER in 2015, I was worried about my health, but I wasn’t worried about bankruptcy because I knew that Medicaid would pay the bill. I can’t imagine the stress of not knowing whether I’d make it until morning with the added worry of bankruptcy heaped on top.

When some of the best clinicians in the world came down to the ER to tell me that they didn’t know what was wrong and I needed to be admitted to the hospital, I knew that Medicaid would pay for that too. When the only option left was surgery to remove infected sections of my small intestine, Medicaid paid for the surgery. When I spent five months not eating a single bite of food, instead getting my nutrition through an IV that whirred away, pumping into my bloodstream for 8 hours every night, Medicaid paid.

Between 2015 and 2016, keeping me alive generated more than $700,000 in medical bills, all covered by Medicaid. And so far the total cost of my medications in 2017 has been $97,907. Without the treatment paid for by Medicaid, I would be dead.

Graham-Cassidy, remarkably, is the worst Republican healthcare proposal yet, and it comes thanks in part to former senator Rick Santorum, whom Pennsylvania voters declined to reelect in 2007. Despite no longer being a member of Congress, and losing the Republican nomination for president to Donald Trump (how embarrassing) last year, Santorum has thrust himself into the healthcare debate. Last week, he joined Republican Senators Lindsey Graham, Bill Cassidy, and Dean Heller in announcing their latest plan to repeal Obamacare. In other words, he came out of retirement to throw red meat to the GOP’s barking base. Perhaps he was lured back to Capitol Hill by the prospect of attacking reproductive justice: Graham-Cassidy, if it passes, would defund Planned Parenthood, one of Santorum’s pet projects.

Grandma Out On the Street

When my grandmother broke her hip a few years ago, she was sent to a nursing home for rehab. For weeks, I’d drive over to the nursing home every morning and give Grandma a pep talk, cajoling her to really work hard in physical therapy. I hated pushing her, but her injury was severe and Medicare only pays for 100 days of nursing home care per illness or injury, no matter how serious. There wasn’t much time.

That’s right: Medicare, the health insurance program for older Americans, only pays for short-term nursing home care. It’s actually Medicaid that pays the bill for most of the 1.4 million people in nursing homes in the United States, including for seniors. Medicaid, which provides health coverage to lower income people, is funded jointly by the federal government and by individual states. For traditional Medicaid enrollees (people with disabilities, seniors, and families with children) the exact percentage of a state’s total Medicaid bill that the feds pick up ranges from 50 to 75 percent.

Graham-Cassidy would shred that cost-sharing formula and replace it with a “per capita cap.” The feds would give each state a fixed amount of money per Medicaid beneficiary, regardless of how much that person’s care actually costs. Meaning, a state would get the same payment for a healthy senior living at home as for my grandma, who takes 14 pills a day and needs surgery later this year. They would get the same for a healthy 30-something who doesn’t go to the doctor as they would for someone like me, whose monthly pharmacy bill averages about $10,000.

In theory, that could work if the per-person payment was large enough. Spoiler: under Graham-Cassidy, it isn’t. Graham-Cassidy would cut Medicaid for seniors and people with disabilities by $175 billion between 2020 and 2026. There simply wouldn’t be enough money left to cover all of the treatment we need.

Graham-Cassidy Breaks the Promise of Medicaid Expansion & ACA Subsidies

It isn’t just the elderly and disabled who will be hurt by this latest Republican plan. Obamacare gave states the option of expanding Medicaid to cover lower-income adults ages 18 to 65 who earn up to 138 percent of the federal poverty level (that’s $16,643 per year for a single adult). Instead of the feds picking up 50 to 75 percent of the cost, as they do with the traditional Medicaid enrollees, the ACA promised that the feds will pay no less than 90 percent of the cost of covering this “expansion population.” The states would have to contribute only 10 percent.

This system has provided coverage for about 15 million people in the 32 states that have opted to expand Medicaid under the ACA, including about 600,000 Washingtonians. Graham-Cassidy would end federal funding for the Medicaid expansion.

Beyond the Medicaid expansion, about 12 million people get their health insurance through ACA Marketplace plans. The ACA provides financial assistance to those who purchase Marketplace plans and whose income is between $12,000 to $48,240 per year for a single adult. Graham-Cassidy would end these subsidies.

Instead, states would receive a block grant, a chunk of money to be spent on healthcare however the state chooses. Proponents of Graham-Cassidy claim these block grants will give states the freedom to design healthcare systems tailored to their circumstances.

These are just two of the many problems with that claim:

• The block grants are temporary and would cease to exist after 2026. Starting in 2027, states would be left to fund healthcare on their own, except for the inadequate and capped Medicaid funds from the feds. As someone who occasionally requires incredibly expensive medical interventions in order to stay alive, and as someone who would very much like to still be alive in 2027, that strikes me as problematic.

• As long as a state promises they will use some of the block grant money to “maintain access to adequate and affordable coverage,” they can effectively wipe out protections for people with pre-existing conditions. If you have a pre-existing condition, insurers will still be required to sell you a policy, but they will be permitted to set an astronomical premium. For example, someone with an autoimmune disease, like me, could be charged $26,000 per year.

What’s more, even if you have health insurance through your employer, you might not escape from Graham-Cassidy unscathed.

• States could let insurers exclude vital healthcare services like prescription medication, maternity, or inpatient hospitalization from individual and employer sponsored plans.

• States could also permit insurers to bring back annual and lifetime caps on coverage. I would’ve blown through the typical lifetime cap of $1,000,000 in just the last three years. And for a cancer patient doing expensive chemo or a newborn in the NICU, it easy to rack up more than $1 million in medical bills in a single year.

Graham-Cassidy is a terrible hodgepodge of the worst ideas from the failed repeal efforts that have come before it. But Graham-Cassidy also innovates. By proposing new and savage cuts to Medicaid, states would struggle to pay for Medicaid nursing care and grandmas, nans, babcis, grans, and meméres all over the country could be out on the street.

All told, about 32 million people would lose their health coverage as a result of Graham-Cassidy. And as a direct result, thousands of people will die prematurely due to lack of access to healthcare. Including, quite possibly, me.