The Senate Health Care Bill (the BCRA) and Its Appeal to Voters

By Lambert Strether of Corrente.

There’s been a lot of wonkish analysis about how bad this Republican health care bill is — they called it Better Care Reconciliation Act (BCRA), if you can believe it — and it is bad, but there’s been very little analysis about why the Senate bill is structured as it is, other than Republicans are mean. Before moving on, let me dispose of the partisan conflict by reposting Matt Bruenig’s chart and interpretation:

Under AHCA, nearly 540,000 people will die in the next decade because of lack of health insurance coverage. For Obamacare, it is a more respectable 320,000 deaths.

In other words, what we have in this week’s battle is a struggle between the two major parties about how efficiently to implement Rule 2 of Neoliberalism. I’m waiting for the liberal Democrat explanation of why 540,000 deaths are bad, but 320,000 deaths are jake with the angels, when there’s a 0-deaths alternative available. Until we get one, liberal Democrats have no standing for virtue signaling whatever.[1] All the liberal Democrats want to do is hit you with a softer hammer.

On to the politics of it (after I caveat that the Senate bill is a moving target, not least because the waverers have to be bought off have their concerns addressed, and so constituencies served, or dis-served, may need to be recalibrated as we go along. Whether there’s a solution space among the Republican factions is, at this point, not known, but all agree the vote will be a near-run thing[2]).

So, what are the constituencies (or potential constituencies) that the Republicans are taking “care” of with the BCRA? Let’s follow the money!

First — and I know this will come as a shock to you, if only because it’s crassly overt — the wealthy end up with more money. Obama wrote on Facebook:

The Senate bill, unveiled today, is not a health care bill. It’s a massive transfer of wealth from middle-class and poor families to the richest people in America. It hands enormous tax cuts to the rich and to the drug and insurance industries, paid for by cutting health care for everybody else. Those with private insurance will experience higher premiums and higher deductibles, with lower tax credits to help working families cover the costs, even as their plans might no longer cover pregnancy, mental health care, or expensive prescriptions.

Of course, the BCRA isn’t a literal transfer of wealth, since Federal taxes don’t fund Federal spending, but the wealthy as a class (along with Obama and the political class) believe that it is.

Now in what follows, I’m going to make use of the handy interactive map that Kaiser just published:

This map compares county-level projections of premiums and tax credits for marketplace enrollees under the Affordable Care Act (ACA) in 2020 with estimates for the Better Care Reconciliation Act (BCRA) as unveiled June 22 by Senate Republicans.

(Remember, the BCRA is a moving target. But for looking at political goals prior to sausage-making, a first draft will do perfectly well). I’m going to move through the age cohorts, and set Kaiser’s income dropdown to the median for each cohort. Basically, orange means that you get money from the Republicans (you pay less) and blue means the Republicans take money away from you (you pay more).

Second, youth. Kaiser:

There’s a lot of orange on that map! So, the Democrats let you get on your parents’ policy ’til you’re 26. Then the Republicans cut the cost of your policy when you’re 27. Sweet! (Speculating, New York and California are outliers because they’ll never vote Republican; Texas is an outlier because it will always vote Republican. I’d also guess that Texas is much more capable of aligning state policy to (Republican) Federal policy than New York and California are).

Third, swing states (that is, the states — and counties — that swung campaign 2016 for Trump). Kaiser:

(See “From ObamaCare to TrumpCare: The Politics” for more on counties in those swing states. If Trump delivers on BCRA price cuts, as opposed to promising to do so, those counties are going to need more than one (monopoly) health insurance supplier.)

Fourth, most definitely not elders. Kaiser:

Blue for ice floes! Still, ask yourself if these 60-and-overs are Republican voters, and the answer is probably not. Medicaid recipients and people warehoused in nursing homes tend not, I would guess, to vote Republican, if they vote at all.


Obviously, this is just a sketch; a full analysis would put population numbers next to the age cohorts, look seriously at income, be granular down to the precinct level, include likely voters, and so on. However, I hope you are at this point disabused of the notion that the BCRA is just crazy, random cruelty. There’s cold-eyed political calculation behind the bill, and I’m sure in some back room, professionals are running the numbers just as efficiently and effectively as Republicans did for, say, gerrymandering, and that they will be willing to share those numbers with any wavering Senators (along with other goodies).

It should be an interesting week. “More money in your pocket” often works.


[1] She’s gone round the twist:

Of course, Clinton’s tweet is richly ironic in so many ways, not just on the health care issue.

[2] The five Republican Senators who have come out against the bill are: Sen. Rand Paul, R-Kentucky*, Sen. Ted Cruz, R-Texas, Sen. Mike Lee, R-Utah, Sen. Ron Johnson, R-Wisconsin, Sen. Dean Heller, R-Nevada*. * = Medicaid expansion states. Interestingly, McConnell is from Kentucky.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


    1. Lambert Strether Post author

      Yes. Only two of the five holdouts are in Medicaid expansion states. So we’ll see how (or if) McConnell can square that circle and not fracture the party (that being his job).

  1. RUKidding

    Seems pretty clear to me that all of the politicians are quite A-OK with US citizens dying without adequate health care as long as they and their patrons in the 1% are extracting rent before you die a horrible death.

    Have I missed anything?

      1. RUKidding

        Read it already; commented here and there.

        Recommended reading to anyone who missed it.

    1. Jonathan Holland Becnel


      I think that pretty much sums it up.

      Makes it easier for the revolutionaries to cut thru the noise ?

  2. RUKidding

    Nancy Pelosi duly adjured us that Single Payer was “off the table” and to never ever ever ask for it again.

    I believe that Ossoff dude in GA also said that he was opposed to Medicare for All. Then he lost.

    Wonder why.

    1. Lambert Strether Post author

      Indeed. And the California Democrat Party Deck Chair threw SB562 in the freezer, supported by not only Planned Parenthood but the SEIU (who funded anti-single payer efforts in 2009). So the establishment is not only circling the drain, but the wagons. Wonderfully clarifying!

      1. RUKidding

        Indeed and most disappointing. I live in CA. Wasn’t completely surprised but am disappointed to be fooled once again.

        Feel like we’re really screwed here.

          1. Darn

            I thought SB562 was kicked into the long grass for being “woefully incomplete” i.e. lacking funding mechanism and how to get the federal funds it would need diverted into state coffers first. That sounds legitimate to me or am I missing something?

            1. RUKidding

              Then why not, you know, work on those issues and continue to investigate Single Payer in CA? Sounded to me like they just kicked it the curb, shrugged their shoulders & said: Eh? Too hard to do. Too bad, so sad, get used to it, VOTE FOR ME!!!!!

            2. Sluggeaux

              The Assembly Speaker’s message about tabling AB562 is that he’s in favor of Single Payer, but he’s making AB562 a “Two-Year Bill” over the current two year legislative session so that they can work out the funding and the kinks in the design of the bill.

              AB562 is far from dead.

              1. Darn

                Confused at AB vs SB now. To clarify, I want them to pass single payer even if it means mega tax increases, I saw polling showing when told of taxes popularity goes down to “only” 40+%. Fine by me. But, biggest tax increase in CA history was a third, by Reagan to balance the budget, and this would be way more than that. Congress isn’t gonna redirect the federal funds into the programme while the GOP are in control.

      2. jrs

        if we had single payer, we wouldn’t need planned parenthood (well any single payer worth having would cover birth control medicines and procedures at least).

        1. Darn

          Dems who support the Hyde Amendment makes me wonder if single payer could get passed without excluding abortion…

          1. WeakenedSquire

            One of the many reasons why single-payer is unrealistic. I personally favor going the other direction and banning public and private health insurance altogether.

            Coupled with a jobs guarantee or a minimum income, people would pay for health care themselves, eliminating the govt and insurance-company middlemen and most of the admin costs that go along with them.

            To pay large bills, people would join health sharing cooperatives where members agree to pay a certain amount each month to fund each other’s care. There are already religious versions of these, grandfathered under the ACA, that work well (naturally, their members don’t pay for each other’s abortions or treatment for certain other conditions that for whatever reason are deemed ungodly).

            The ACA actually bans the formation of new health sharing cooperatives, but if that ban were lifted, Planned Parenthood, for example, could start its own cooperative that would allow its members to fund each other’s abortion care.

  3. flora

    Hmmm…. better material benefits for the young who may then associate the GOP with material benefits and continue voting GOP as they age — even thought the material benefits are calculated to recede, then vanish as they age. Sounds like a plan I’ve seen used elsewhere.

    Great post.

  4. Carla

    Where’s the map with where the tax cuts “paid for” by further crapified healthcare are going? (I know, it would have to be a VERY large blue map with just a few tiny, tiny orange dots. Maybe it wouldn’t be as dramatic).

    1. Lambert Strether Post author

      I suppose one could construct such a map of “winning” and “losing” counties if you used income as a proxy for wealth, but I would bet a lot of the actual money ends up offshore. We’d really need to track high net-worth individuals, and that’s not easy.

      1. Carla

        I just think we need to always point out that they’re the real winners, and the only winners, not the folks in the orange states.

        1. lambert strether

          The headline reads “appeal to voters,” who vote in jurisdictions, colored orange or blue. The conclusion discusses the political logic, the topic of the post

  5. Jim Haygood

    Obama wrote on Facebook: The Senate bill, unveiled today, is not a health care bill. It’s a massive transfer of wealth from middle-class and poor families to the richest people in America.

    Obama’s remark illustrates a couple of things. One is the ratchet effect. BCRA repeals a 3.8% tax on capital gains, dividends and interest income and an 0.9% surtax on wage income for those earning over $250,000, restoring the pre-ACA status quo.

    Whether or not one agrees with reverting income taxes to their 2010 levels, Obama’s rhetoric creates the deceptive impression of a vast new “transfer of wealth,” as if the ACA had always been with us. Tax policy having always been fluid, Obama’s ACA taxes could be regarded as a 7-year aberration which is now being phased out along with collapsing insurance “markets.”

    Second and more importantly, Obama’s continuing engagement with policy minutiae shows that like the Clintons, Obama lacks any concept of the dignified tradition of ex-presidents withdrawing from the political fray. Permanent campaigns and barbed policy wonkery from those who’ve had their turn in the Oval office are a peculiarly Democratic vulgarity. And it’s not working.

    1. mtnwoman

      I don’t remember Cheney shutting up.

      I’m happy for anyone and everyone — including the subject of many of Trump’s infantile, lying, paranoid tweets (Obama) — to oppose this cruel, greedy bill by the GOP that takes us further into a 2nd world health care system just so the rich can be filthy richer.

      1. a different chris

        Yeah and I couldn’t care less about anybody’s dignity when this kind of stuff is at stake. Not that I don’t seriously wish the Clintons would just go away. Obama, dunno, he has that rhetorical style and now that he’s can’t use it to lipstick his many pigs maybe it will actually do good this time.

  6. marym

    National Association of Medicaid Directors (PDF)

    The Senate bill does formalize several critical administrative and regulatory improvements, such as giving Medicaid Directors a seat at the table in the development of regulations that impact how the program is run, and the pathway to permanency [*] for certain waiver programs.

    However, no amount of administrative or regulatory flexibility can compensate for the federal spending reductions that would occur as a result of this bill.

    Changes in the federal responsibility for financing the program must be accompanied by clearly articulated statutory changes to Medicaid to enable states to operate effectively under a cap. The Senate bill does not accomplish that. It would be a transfer of risk, responsibility, and cost to the states of historic proportions.

    While NAMD does not have consensus on the mandatory conversion of Medicaid financing to a per capita cap or block grant, the per capita cap growth rates for Medicaid in the Senate bill are insufficient and unworkable.

    * NB something we should be watching too – Reps are so much better than Dems in making their changes unchangeable.

  7. David, by the lake

    I agree with single-payer conceptually, but still argue that it should be managed at a state or regional (cooperating groups of states) level, due to inherent differences in opinion as to what should be covered and how programs should be managed. Rather than continually attempting to force the entire country to adopt a single program, let’s allow differences in detail. Again, perhaps the central levers of control shouldn’t exist in the first place…

    Ironically, the present battles may actually get us to such an arrangement, as state level single payer proposals continue to surface.

    1. Bobby Gladd

      to wit:

      “What Scandinavian governments do better than most is to balance “upstream” work to keep people healthy through adequate services in the social sphere, with “downstream” work of medical care for people after they have become ill. In accepting a broad view of the determinants of health, Scandinavian policies allow social and medical services to be planned and managed together, in many cases. Local governments— county councils or municipalities— are responsible for a pool of resources that has to finance both health and social services. For instance, Norwegians who face illness can count on a variety of municipality-funded social benefits designed to keep people functioning at home, with less need for expensive medical care in a hospital or nursing home. A director of health services for a municipality in Norway (ID 67) explained:

      Today you can get help for house cleaning, for shopping, and we also spend a lot of money to support or subsidize traveling in taxis to get anywhere [needed]. Not only to the doctor. 76

      Although the ability of these decentralized authorities to tax citizens differs across the countries, in all three contexts, local bodies run by locally elected officials are responsible for making choices between the financing of health and of social services to produce a tailor-made approach to health that best serves their community. This integration of power and control at the municipal level brings with it a critical sense of collective accountability for health, from which the United States may learn…”

      Bradley, Elizabeth H.; Taylor, Lauren A. (2013-11-05). The American Health Care Paradox: Why Spending More is Getting Us Less (Kindle Locations 1897-1909). PublicAffairs. Kindle Edition.

  8. Kim Kaufman

    Heard yesterday on NPR’s All Things Considered:

    Where Does The Federal Budget Deficit Fit Into The Health Care Equation?

    NPR’s Michel Martin speaks with Committee for a Responsible Federal Budget [also the Campaign to Fix the Debt] President Maya MacGuineas about how to balance the need for health care with the need to reduce the federal budget deficit.

    And right after the above story, this:

    Activists On The Left Seek To Harness Spending As Part Of Their Anti-Trump Resistance

    “”It is basically America’s swear jar but for toxic ideology,” she said. “So every time Trump goes on a Twitter rampage or tweets something dangerous or hateful, the app lets you automatically donate to a nonprofit that’s fighting to protect our democracy, human rights, or the environment,” she explained.”

    1. RUKidding

      I saw something today that linked to a KellyAnn CONway appearance on Fox probably where allegedly she spouted the usual crap line about: “Most citizens will continue getting their health care through their employers, which is what we want citizens to do. ” Or something along those lines.

      Eh? I thought the whole big deal appeal of that schlameal, Trump, was that he was this big time “populist” who was reassuring the “economically anxious” (don’t you dare call them racist) WWMEN, who didn’t have jobs ‘n stuff.

      So which is it? Are Trump voters supposed to have jobs now and can be ignored and told to STFU And FOAD?? Or what?

      Duly noted, also, that Carrier – you know, that air con plant in some flyover state that Trump supposedly made one of his faaaabulous DEALS with to not remove jobs to Mexico – is NOW moving those jobs (something like 1000?) to Mexico.

      So I guess Trump voters there should just STFU and, you know, get another job with benefits, like they’re supposed to. I guess it doesn’t matter to those 1000 Carrier employees that they’re losing their employer health benefits bc I’m sure that there’s LOADS of other well-paying jobs with benefits just going begging right down the street from where they live.

      Talk about voting against your interests. That said, what a sh*t-rotten non-choice we had in November.


        1. RUKidding

          Well of course the solution then is to just get another job with better benefits.

          And as for those losing Medicaid, then they better just get a job, too, including my aged friend who can no longer walk. She needs to just get over it, get out of her wheel chair and get a job at age 88.

          That’s the ticket.

        2. allan

          If only someone had warned us:

          The Republicans’ health care plan for America: “Don’t get sick.” That’s right — don’t get sick. If you have insurance, don’t get sick; if you don’t have insurance, don’t get sick; if you’re sick, don’t get sick — just don’t get sick! That’s what the Republicans have in mind for you, America. That’s the Republicans’ health care plan. But I think that the Republicans understand that that plan isn’t always going to work — it’s not a foolproof plan. So the Republicans have a backup plan, in case you do get sick. If you get sick in America, this is what the Republicans want you to do. If you get sick, America, the Republican health care plan is this: “Die quickly.” That’s right. The Republicans want you to die quickly if you get sick.”

          The good news is that selling across state lines will unleash the magic of the marketplace and sparkle ponies will descend from Heaven to empower individual consumers to right-size their in-network deductibles and out-of-network out-of-pocket maximums
          and make Paul Ryan’s college dream of killing Medicaid come true.

          1. Bobby Gladd

            Ah, yes, the Magical “Free Market.” Gotta love it. One small graphical nit-pick:


            Beyond that, any market that is “free” is — well — free to exploit any and every moral and economic power asymmetry that exists, right (just ask Travisk)? Every expedient Gresham’s Dynamic tactic at hand, right?

            (Cue the poignant “No True Scotsman” Free Market Magical Thinker beg-offs in 3, 2, 1…)

    2. jrs

      being middle class most of Trump’s base will probably be ok, of course some won’t. The Dem base will of course have it worse, as they are overall poorer.

      1. RUKidding

        Well I don’t know if that’s exactly true. I thought a significant portion of Trump’s base were “economically anxious” WWMEN in what’s called flyover country/aka the heartland. I thought a lot of those voters didn’t have any jobs, and the reason why they voted for Trump was because he was supposed to help them get jobs.

        So which is it?

        Are Trump voters all rich people? Or are they working class and jobless?

        No offense, but I get this argument from others – that Trump’s voters are all wealthy and won’t feel the burn – as if that makes this Death Panel Legislation OK or something (after all, it’s only poor Democratic voters, who’ll get the shaft, so FOAD). But that doesn’t connect with what we saw at Trump rallies all last year and continuing into this year.

        Is it OK, then, to just shaft the poor, no matter how they vote, just so long as middle class and wealthy people are sitting in clover?

        Just saying…

        1. lambert strether

          Trump’s base in wealthy suburbs will be fine. The marginal voters who put him over the top, dome of whom flipped from voting for Obama, will not be fine.

      2. Carla

        Remember when you speak about the Trump base and the Democrat base that 26% of voters are Republicans, 29% are Democrats and 42% are independents. It was the independent voters who made the difference for Obama in ’08 and ’12, and for Trump in ’16.

  9. robnume

    I am so angry about Rendon’s unrendering of our Single Payer initiative that I decided to do a little homework aka “follow the money.” I found a lot of imformation on this turkey but here are a couple which kind of spell out Rendons position on single payer and the Dem party at large. and Rendon is a total tool.
    Thanks so much to Yves, Lambert and Jerri Lynn for their fine relentless coverage on this most important issue.

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