Popular vote loser Donald Trump freely admits he called the House version of Trumpcare “mean, mean, mean” and also claimed that he wanted a Senate bill that is “generous, kind, with heart.” That’s not what he got with the Senate version of Trumpcare, the “Better Care Act.” In fact, the Congressional Budget Office says it’s just as mean by the numbers, if not more so.
According to their estimates, 15 million people will lose their insurance next year, 2018. An election year. By 2026, 22 million people who are now insured will have lost that insurance. Compared to the Affordable Care Act, “an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.” The biggest hit, as in the House bill, lands on Medicaid.
The largest savings would come from reductions in outlays for Medicaid—spending on the program would decline in 2026 by 26 percent in comparison with what CBO projects under current law—and from changes to the Affordable Care Act’s (ACA’s) subsidies for nongroup health insurance. Those savings would be partially offset by the effects of other changes to the ACA’s provisions dealing with insurance coverage: additional spending designed to reduce premiums and a reduction in revenues from repealing penalties on employers who do not offer insurance and on people who do not purchase insurance. […]In later years, other changes in the legislation—lower spending on Medicaid and substantially smaller average subsidies for coverage in the nongroup market—would also lead to increases in the number of people without health insurance.
Keep in mind that “later years” part. This estimate doesn’t go beyond 2026; however the CBO doesn’t think that the so-called “flexibility” for Medicaid that block granting would be for states is all that. Instead, it would be a burden. “With less federal reimbursement for Medicaid, states would need to decide whether to commit more of their own resources to finance the program at current-law levels or to reduce spending by cutting payments to health care providers and health plans, eliminating optional services, restricting eligibility for enrollment through work requirements and other changes, or (to the extent feasible) arriving at more efficient methods for delivering services.” It also projects that post-2026, Medicaid enrollments would continue to fall.
People with individual plans will see “substantial increases in out-of-pocket spending, even though benchmark premiums would decline, on average, in 2020 and later years.” That’s because insurance would pay for a smaller share of benefits. That’s going to be true for “close to half the population, CBO and JCT expect—living in states modifying the EHBs [essential health benefits] using waivers. People who used services or benefits no longer included in the EHBs would experience substantial increases in supplemental premiums or out-of-pocket spending on health care, or would choose to forgo the services.”
In some areas of the country—particularly sparsely populated ones (are you listening Lisa Murkowski)—the CBO foresees a market collapse, the classic death spiral. “Some sparsely populated areas might have no nongroup insurance offered because the reductions in subsidies would lead fewer people to decide to purchase insurance—and markets with few purchasers are less profitable for insurers.”
Yes, this bill is mean, mean, mean. But hey, it’s got lots of tax cuts for the very rich, so expect most Republicans to overlook the other parts.
R&R - Reachout and Rebuild 
The state by state approach also slyly makes organizing victims to fight this harder by fragmenting them, right?
It also makes it somewhat easier to “bribe” recalcitrant Senators by offering local “fixes,” but this bill seems so toxic, a repair job looks to be a difficult task.