The health care debate - up to date as of June 15, 2017 1) Health care troubles, 2) ACA accomplishments and problems, 3) 20 AHCA characteristics and problems, 4) Single payer as solution

1. WAS ORWELL
RIGHT BUT
33 YEARS
OFF??

2. MEDICAL CARE in the USA
TODAY:
“FRANKLY, I DON’T GIVE A DAMN!”
JEOFFRY GORDON, MD, MPH
paradocs2@hotmail.com
June, 2017
“In their high-stakes strategy to overhaul the federal health law, President Donald
Trumpand the Republicans arethreatening to upend the individual health insurance
marketand Medicaid with several keypolicies. But if the marketactually breaks,
could anyoneput it back together again?”

5. It was Ronald Reagan who
said “Freedom is always just
one generation away from
extinction. We don’t pass it
to our children in the
bloodstream; we have to
fight for it and protect it, and
then hand it to them so that
they shall do the same, or
we’re going to find ourselves
spending our sunset years
telling our children and our
children’s children about a
time in America, back in the
day, when men and women
were free.”

6. Life expectancy increases continuously with income. At the age of 40 years, the gap in
life expectancy between individuals in the top and bottom 1% of the income
distribution in the United States is 15 years for men and 10 years for women. Gaps in
life expectancy by income increased between 2001 and 2014. Life expectancy did not
change for individuals in the bottom 5% of the income distribution, whereas it
increased by about 3 years for men and women in the top 5% of income distribution.

7. A National Center for Health Statistics report shows that life expectancy in 2015 is
declining in America. The overall death rate rose 1.2 percent in 2015, its first uptick
since 1999. Besides war, plague and famine, there have been few moments in all of
human history when that has happened. This is more troubling because it is not
happening in other western countries. Death rates rose for white men, white women
and black men. This happened despite a drop in the death rate from cancer, thanks to
fewer people smoking and better chemo.

10. Death rate for U.S. non-Hispanic whites (USW), U.S. Hispanics and six comparison
countries, aged 45-54. (Source: Proceedings of the National Academy of Sciences.)
A large segment of white middle-aged Americans has suffered a startling rise in its death rate since
1999 showing a sharp reversal in decades of progress toward longer lives. The mortality rate for white
men and women ages 45-54 with less than a college education increased markedly between 1999 and
2013. An increase in the mortality rate for any large demographic group in an advanced nation has
been virtually unheard of in recent decades, with the exception of Russian men after the collapse of
the Soviet Union.
“Drugs and alcohol, and suicide . . . are clearly the proximate cause,” said Angus Deaton, the 2015
Nobel laureate in economics, who co-authored the paper with his wife, Anne Case. Both are
economics professors at Princeton University. “Half a million people are dead who should not be
dead.”

13. From 2000 to the end of 2010, Texas’s maternal
mortality rate hovered between 17.7 and 18.6 per
100,000 births. But in 2011, that rate had leaped to
33 deaths per 100,000, and in 2014 it was 35.8.
Between 2010 and 2014, more than 600 women
died for reasons related to their pregnancies. Black
women, who accounted for 11.4% of births in Texas
in 2011 and 2012, had 28.8% of deaths linked to
pregnancy. In 2011, just as the spike began, the
Republican-led Texas state legislature cut $73.6m
from the state’s family planning budget of $111.5m.
The two-thirds cut forced more than 80 family
planning clinics to shut down across the state.

16. The federal government accounts for nearly 60% of all the healthcare money
($370B total) spent in California, via Medicare and Medicaid funding and tax
deductions for premiums paid by employers and employees.

17. THE ACA TRANSFORMED ACCESS TO MEDICAL CARE BY:
1. Protecting people with pre-existing conditions (“community rating”).
52 million people — about 1 in 4 non-elderly Americans — have preexisting conditions. These Americans are more
likely to face significant health costs, and before the Affordable Care Act, were often denied coverage entirely.
2. Letting young adults stay on their parents’ plan.
Over 6 million young adults can stay on their parents’ health care plan until they are 26. 85 percent favor keeping
young people on their parents’ insurance plans.
3. Creating a health insurance market for individuals and the poor who could previously
not afford it. On January 31, Open Enrollment for 2016 coverage ended, with 12.7 million consumers enrolling
in Marketplace coverage, over 9.6 million came through the HealthCare.gov platform and 3.1 million selected a
plan through State-based Marketplaces.
4. Eliminating differential insurance premiums for the sexes, minimizing age premium
differentials ( to a 3:1 difference) , i.e. “Community rating.”
5. Expanding Medicaid to all adults over 138% of poverty (eliminating ‘catagorical’
restrictions). In January, 2016 72.9 million people were enrolled in Medicaid and CHIP. Between Summer 2013
and January 2016, there was a net increase of nearly 15.5 million mostly due to the ACA.
6. Specifying a minimum standard of benefits, including substance abuse and
alcoholism treatment, including no charge for preventive services. Vastly expanding access to
mental health and addiction treatment, by designating them as “essential benefits” that must be covered through
the A.C.A. marketplaces and expanded Medicaid.
7. Narrowing and then eliminating the Medicare prescription gap (donut hole). Nationally,
9.4 million people with Medicare have saved over $15 billion on prescription drugs since the ACA’s enactment, for
an average savings of $1,598 per person.
8. Subsidizing insurance premiums, copays, and deductibles for 80+% of those signing
up on the exchanges due to relative poverty.
9. Investing $10 B in community health centers.

18. The ACA extended
the life of the
Medicare Trust fund
at least until 2029—
a 12-year extension
-- due to reductions
in waste, fraud, and
abuse, and
Medicare costs.

19. How the Affordable Care Act Drove Down Personal Bankruptcy:
Expanded health insurance helped cut the number of filings by half
CONSUMER REPORTS, May 02, 2017
“It’s absolutely remarkable,” says
Jim Molleur, a Maine-based
bankruptcy attorney with 20
years of experience. “We’re not
getting people with big medical
bills, chronically sick people who
would hit those lifetime caps or
be denied because of pre-existing
conditions. They seemed to
disappear almost overnight once
ACA kicked in.”

20. By expanding Medicaid to all adults over 138%
of poverty and eliminating ‘categorical’
limitations, ACA was designed to provide free,
universal, health access to all legal, poor
residents in the US. The Supreme Court as
opined by Chief Justice Roberts destroyed this
design: “Nothing in our opinion precludes
Congress from offering funds under the
Affordable Care Act to expand the availability
of health care, and requiring that states
accepting such funds comply with the
conditions on their use. What Congress is not
free to do is to penalize states that choose not
to participate in that new program by taking
away their existing Medicaid funding.”

21. The ACA raised the income threshold for determining the tax deduction for medical
expenses and created two extra taxes on high-income individuals - a 0.9 percent
payroll Medicare surtax on earnings and a 3.8 percent tax on net investment income
(NII) for individuals with incomes exceeding $200,000 ($250,000 for couples) The high-
income surtaxes are projected to raise $35 billion in 2020. Nearly all families affected by
the additional taxes are in the top five percent of income with most of the burden borne
by families in the top one percent of income. Both through new taxes on the wealthy
and by subsidizing health insurance/medical care for the poor and lower middle class
the ACA clearly reduced broad measures of inequality. It was the biggest attack on
economic inequality since inequality began rising four decades ago.
Eliminating all the ACA taxes would cut taxes by an average of $180 per household in 2017—a 0.3 increase in
after-tax incomes. Most low-income households would see no change at all in their taxes. On average, the
lowest-income households (that make less than about $25,000) would see their taxes rise by $90, or about 0.6
percent of their after-tax income. By contrast, nearly everyone in the highest income one percent would enjoy
a substantial tax cut, averaging $33,000 or about 2.1 percent of after-tax income. Those in the top 0.1
percent would get an average tax cut of about $197,000, raising their after-tax incomes by 2.6 percent,
thanks to the repeal of the net investment tax and the extra Medicare tax.

22. ACA PROBLEMS: POLICY & FUNCTION
(1) Insurers are asking state regulators in Connecticut, Oregon, New Mexico, North
Carolina, Maryland, District of Columbia and Virginia for permission to raise
premiums by more than 20% and as much as 53% in 2018.
(2) Commercial health insurers may choose not to participate at all. UnitedHealth
Group wants ACA markets disbanded entirely beginning in 2019 and oversight of the
individual market returned to states, wants to eliminate the ACA's essential health
benefits and its metallic actuarial value-rating system, and restore the ability of insurers
to sell short-term and limited coverage policies. Aetna which had plans in four states in
2017 will stop selling individual insurance plans on and off the ACA in 2018. The
company has just 255,000 members and expects to lose $200 million on individual plans
this year. The insurer said it lost $450 million in 2016, when it insured 964,000 individual
ACA members. Aetna's total 2016 revenue totaled $60.2 billion, while its profit was $2.3
billion. Anthem will not return to Ohio’s public insurance exchanges in 2018 and is the
only insurer selling marketplace plans in all 88 Ohio counties this year, and the only
insurer at all in 20 of them. Next year, an estimated 10,500 people in one-fifth of Ohio’s
counties may have no plan options at all.
(3) Out of pocket expenses are very high for unsubsidized enrollees (205 of total).
(4) Cost containment has been minimal.

23. Leader McConnellVerified account @SenateMajLdr #Obamacare continues to fail the
American people. Are Democrats ok with dwindling choices?
As of June, 2017

24. Trump reportedly told a closed-door gathering of GOP senators that the
House repeal-and-replace bill is “mean” and called on them to make it
“more generous.” G.O.P. Senators Might Not Realize It, but Not One State
Supports the A.H.C.A.
The GOP’s fantastically anti-democratic quest to kill health care in the dark
By E.J. Dionne Jr., WASHINGTON POST, Opinion writer June 14, 2017
Republican hypocrisy is now so rampant that it’s typically ignored or, worse, granted
the political class’s all-purpose form of absolution: “Everybody does it.” McConnell is
trying to eviscerate the Affordable Care Act using methods completely at odds with
how the law was originally brought to life in the early Obama administration. The
ACA was debated for more than a year and went through an elaborate hearing and
amendment process that included some changes urged by Republicans. By contrast,
the bill Senate Republicans are writing is being held as close as the nuclear codes.
Why all the secrecy? McConnell is trying to keep the pressure off the many
Republican senators who have offered pledges of varying degrees of specificity to
protect Medicaid and other aspects of the ACA that benefit their constituents.
Democrats have 48 votes against dismantling the existing law. This legislation could
threaten the health care of countless Americans (the exact number being
unknowable because the bill’s architects won’t admit to what they’re doing)?
Jacob Leibenluft, a former Obama administration official, said “I hate to think that
looking back on this period, we’ll realize that the most regressive piece of social
legislation in modern American history was passed, and no one was paying
attention.”

25. THE AMERICAN HEALTH CARE ACT: THE BOTTOM LINE
The CBO's estimates (May, 2017):
By 2026 23 M people who would have had health insurance under ACA
would be uninsured,
“Insurance premiums would rise up to 850% for rural, elderly, poor people
over the next decade,”
By 2026 federal direct spending on health care would be reduced by
$1.111T,
By 2026 federal revenues would be reduced by $992B (including a $600B
tax rebate to the TOP 1%) limiting the net federal deficit reduction to
$119B.
There is a sentence in the CBO report that is particularly alarming. Under the
AHCA, the report states, “About one-sixth of the population resides in areas in
which the nongroup market would start to become unstable beginning in 2020.“
To break that down, although the report does not use the phrase "death spiral,"
but the "areas" the report refers to are mostly red states, and the "nongroup
market" refers to people who do not have health insurance through an employer
or through the government and "unstable" means that people in those two
categories who have preexisting medical problems might no longer be able to buy
insurance.

26. On June 7, Mitch McConnell formally started a fast-track process for the Senate to consider
the House’s health care bill. It’s true that Senate Republicans continue to poor-mouth their
prospects for passing a bill, but that may actually be part of their strategy to do so.
They know that their health care plan is extremely unpopular. It’s a reverse Robin Hood
plan that would take insurance away from or worsen coverage for the middle class, poor,
sick and elderly and use the savings to cut taxes for the affluent. That’s why the plan
is opposed by experts across the ideological spectrum, as well as groups representing
doctors, nurses, hospitals, cancer patients, heart-disease patients and many others.
By downplaying the odds of passage, senators are able to reduce the amount of attention
and public opposition that their deliberations might receive. Meanwhile, they are moving
quickly and almost entirely behind closed doors to come up with a bill that makes only
modest changes to the House-passed bill. Those changes are akin to “adding ketchup to
rotten food,” as Andy Slavitt, who used to run Medicare and Medicaid, put it.
Democratic aides have grown especially worried that the Senate will pass a somewhat
vague bill and then claim that they’ll fix any problems in a process known as conference —
when the House and Senate negotiate over differences between bills that each have passed.
The whole game is distraction. The only way that the House could pass such an unpopular
bill was to keep people from focusing on the substance of the bill, while rushing it through,
and the Senate now seems to be following a version of that strategy.

27. Repealing the ACA: The Final CBO Score of the AHCA (Ryancare), May 2017
(1) Increase the number of uninsured by 14M in 2018 growing to 23M by 2026; the
previous bill would have raised the number of uninsured by 24M in 2026, resulting in a
total of 51M uninsured in 2026, versus 28M under ACA.
(2) Significantly “increase the number of uninsured among people ages 50 to 64 with
income under 200% of poverty.”
(3) Repeal the individual and employer mandate to purchase health insurance
retroactively to January 1, 2016.
(4) Lower federal Medicaid spending by $834 billion over 10 years, reducing Medicaid
enrollment by 14 million in 2026, a 17% decrease by converting virtually the entire
program to a per capita cap or block grant starting in 2020. A Medicaid block grant or
per capita cap policy would fundamentally change the current structure of the program
by reducing federal spending and fixing rates of growth to make federal spending
more predictable, and eliminating the guarantee of coverage for all who are eligible
and the guarantee to states for matching funds. States would gain additional flexibility
to administer their programs but reduced federal funding could shift costs and risk to
beneficiaries, states, and providers. Previous block grant proposals have determined a
base year financing amount for each state and then specified a fixed rate of growth for
federal spending. To achieve federal savings, the per capita growth amounts would be
set below the projected rates of growth under current law.

28. Repealing the ACA: The Final CBO Score of the AHCA (Ryancare), May 2017
(5) AHCA would repeal the ACA’s marketplace premium and cost-sharing tax credits
and subsidies in 2020, substituting an age-based tax credit. The value of the tax credit
the ACHA provides to purchase health coverage in the individual market would equal
only 60% of the value of the ACA’s tax credit, falling to 50% by 2026. These changes save
$290 billion over 10 years reducing spending from $665 billion to $375 billion.
(6) Repeal 3.8% tax on investment income by wealthy people (totaling $662 billion over
10 years,) including delaying until 2023 the 0.9% Medicare (FICA) tax surcharge on
people earning more than $200,000 a year ($250,000 for joint returns) .
(7) Reduce direct spending on health care by $1,111B ($1.85 trillion total reduction in
Trump budget) and reduce revenues by $992B, for a net reduction of $119B in the
deficit by 2026; the prior version of the AHCA would have cut the deficit by $150 billion.
(8) Prompt states where half the U.S. population lives to seek waivers from the ACA's
individual insurance market rules on minimum essential health benefits, use of pre-
existing conditions for setting premiums and guaranteed issue.
(9) Premiums in the individual market would rise by 20% in 2018 and 5% in 2019.
Because of a change in age rating of premiums from a spread of 3X to 5X, premiums for
older people would sharply increase starting in 2020 and would be more than 20%
higher by 2026. However, individual-market premiums would be lower by about 4% in
2026, mainly because more younger, healthier people and fewer older, sicker people
would buy coverage, and the policies available on the market would tend to be a lot less
comprehensive.
(10) Increase Medicare disproportionate-share payments to hospitals by $43 billion
over 10 years due to a jump in uninsured patients.

29. Repealing the ACA: The Final CBO Score of the AHCA (Ryancare), May 2017
(11) Create individual-market instability in states seeking waivers where one-sixth of
the U.S. population lives; premiums for people seeking to buy comprehensive plans
would become unaffordable.
(12) Lower premiums would be associated with substantially increased out-of-pocket
costs for people in states that waived ACA requirements on essential health benefits,
particularly for maternity, mental health and substance abuse services.
(13) Prompt a few million people to use premium tax credits to buy plans that don't
cover major medical costs.
(14) Result in 4 million more people in employer-based health plans by 2026, mainly
because employers would see the individual market as a less desirable option for their
workers.
(15) Beginning in 2018 create a new Patient and State Stability Fund costing $117B over
10 years, plus $15B for a Federal Invisible Risk Sharing Program; plus $15B to states to
use for maternity coverage, newborn care, and prevention, treatment, or recovery
services for people with mental or substance use disorders; plus $8B in funding to states
that obtain a waiver. All this to reduce premiums and out of pocket costs for people
priced out of the insurance market by the newly created state waivers. The total of
$138B is $38B more than the prior draft and is considered to be totally inadequate.
(16) Require insurers to impose a 30% surcharge on premiums for 1 year for people
who enroll in insurance in the nongroup market if they have been uninsured for more
than 63 days within the past year. Under ACA, non-enrollment was a tax penalty paid to
the government.

30. Repealing the ACA: The Final CBO Score of the AHCA (Ryancare), May 2017
(17)Low-income Medicare beneficiaries who also are enrolled in Medicaid (“dual
eligibles”) would be disproportionately affected by AHCA’s cuts and caps to
federal Medicaid financing. These 11M older adults account for 1/3 of all
Medicaid spending and much of the Medicaid spending for low-income Medicare
beneficiaries is “optional” for states. The 72% of dual eligibles who receive full
Medicaid benefits tend to be in poorer health than other Medicare (and
Medicaid) beneficiaries, and rely on Medicaid for high-cost services. While
Medicare covers physician, hospital, and most other acute care, Medicaid covers
some of dual eligibles’ behavioral health services as well as most of their long-
term services and supports, such as nursing home and home and community-
based services. Under federal law, many of these services are optional. Also
because of the close connections between Medicaid and Medicare, reducing the
availability of Medicaid-financed home care services that help people manage
their complex health conditions could mean that more dually eligible individuals )
wind up in the hospital more often. Those costs would be borne by Medicare.
(18) The AHCA would make it more difficult for many workers to get transitional
stopgap health insurance if they leave a job, are laid off, start a business or retire
early that provides a bridge to the next phase of their lives.

31. Repealing the ACA: The Final CBO Score of the AHCA (Ryancare), May 2017
(19) Before ACA’s enactment, the Medicare trust fund, which is used to reimburse
hospitals for treatment provided to seniors, was expected not to have enough funds to
fully cover benefits beginning around 2016. The ACA’s 0.9 percent tax on individuals
earning more than $200,000 (or more than $250,000 for those filing jointly), as well as
reduced payments to hospitals and private insurers under Medicaid Advantage, are
credited with significantly extending the solvency deadline to 2028, according to the
most recent Medicare trustee report. The AHCA repeals that 0.9 percent tax, resulting in
a predicted loss of $117 billion in revenue over the next 10 years and accelerating when
the Medicare trust fund would begin falling short of funds to the end of 2024, nearly
four years sooner than if the tax remained in place.
(20) The AHCA would raise employment and economic activity at first, but lower them in
the long run. It initially raises the federal deficit when taxes are repealed, leading to
864,000 more jobs in 2018. In later years, reductions in support for health insurance
cause negative economic effects. By 2026, 924,000 jobs would be lost, gross state
products would be $93 billion lower, and business output would be $148 billion less.
About three-quarters of jobs lost (725,000) would be in the health care sector. States
which expanded Medicaid would experience faster and deeper economic losses.

34. According to the CBO, the AHCA’s changes include greater latitude for insurers to
charge older customers higher premiums (3:1 changes to 5:1), new waivers under
which states could opt out of certain ACA insurance market rules and changes in the
way tax credits are calculated. Because of these changes, some older adults --
especially those with lower incomes -- could see out-of-pocket costs for insurance
premiums rise by thousands of dollars per year.

35. Using the most recent National Health Interview Survey (NHIS), we estimate that 27.4
million non-elderly adults nationally had a gap in coverage of at least several months in
2015. This includes 6.3 million people (or 23% of everyone with at least a several-month
gap) who have a pre-existing condition that would have led to a denial of insurance in
the pre-ACA individual market and would lead to a substantial premium surcharge under
AHCA community rating waiver.

36. The biggest changes in the AHCA2 cost estimate from the earlier estimate are due to an increase in
revenue of $68 billion from the delay in the repeal of the Medicare tax surcharge on people earning
more than $200,000 a year ($250,000 for joint returns) until 2023, offset by an increase in expenditures
of about $100 billion, including about $38 billion more for the Patient and State Stability Fund

37. 6 States Hoping to Revamp Medicaid in the Trump Era
ARIZONA would require "able bodied individuals" to be working or actively searching for a job. It
would also set a limit -- in this case, five years -- to how long people can be on Medicaid
throughout their lifetime. 11 million people would lose their Medicaid benefits if work
requirements were in place nationwide.
ARKANSAS will kick anyone above 100 percent of the federal poverty line off of Medicaid. Under
the ACA, the federal government foots most of the bill for states that choose to cover people up to
138 percent of the federal poverty line. That would remove 60,000 people from Medicaid rolls
with the expectation that they’ll instead buy insurance on the marketplace.
FLORIDA already submitted a waiver to block grant Medicaid which is said yo give states far more
flexibility.
KENTUCKY wants to make people work for Medicaid.
MAINE is hoping to reintroduce asset tests, which are prohibited under the ACA. If approved,
residents with assets of more than $5,000 would be ineligible for Medicaid.
Asset tests are considered extreme, and many conservatives didn't object when the ACA prohibited
them. Maine is also proposing premiums higher than 2 percent of income for some recipients and
would lock people out of their insurance for 90 days if they miss any payments. Beneficiaries
without a job would only be allowed to receive benefits for 36 months.
WISCONSIN is attempting to introduce drug testing Medicaid recipients. Other proposed changes
include small premiums for childless adults that can fluctuate if participants prove they don’t
engage in risky behaviors like smoking and not wearing a seat belt. Like Maine, Wisconsin also
wants to impose a time limit -- in this case, 48 months -- for unemployed beneficiaries.

38. POTENTIAL IMPACT OF PRESIDENT TRUMP’S VALUES AND POLICIES
President Trump has immediate unilateral ability to eliminate cost-sharing subsidies for ACA’s
poorest customers (saving $9B) as a result of a successful lawsuit brought by House Republicans. In
May, 2016 the Federal District Court ruled for the House, finding that the Health and Human Services
Department had illegally paid billions of dollars in subsidies for reducing deductibles and other out-
of-pocket costs for low-income consumers (7M people ) to health insurance companies which
violated the Constitution because Congress had never provided explicit authority for it. This
development could lead many insurers to flee the ACA’s markets because they’d still be on the hook
for providing reduced costs to their customers, but with no guarantee they’d ever be reimbursed by
the federal government. There are now 47 counties across Missouri, Ohio and Washington with zero
health insurers signed up to sell marketplace plans in 2018.
Trump Seeks Delay of Ruling on Health Law Subsidies, Prolonging Uncertainty, NY Times, MAY 22,
2017 WASHINGTON — The Trump administration asked a federal appeals court to delay ruling on a
lawsuit that could determine whether the government will continue paying subsidies under the ACA to
health insurance companies for the benefit of low-income people. The request could further
destabilize insurance markets just as insurers are developing rates and deciding whether to
participate in 2018. In North Carolina Blue Cross Blue Shield has filed for a 23% rise in premiums, but
declared that it would have asked for only 9% if it were sure that cost-sharing subsidies would
continue. Blue Cross Blue Shield North Carolina lost $450 million on the ACA marketplaces in 2014
and 2015. WASHINGTON — On June 7 the powerful House Republican Kevin Brady of Texas, who is the
chairman of the House Ways and Means Committee, went out of his way to make clear that he now
believes that Congress should immediately provide money for subsidy payments to health insurance
companies to compensate insurers for reducing deductibles and other out-of-pocket costs for seven
million low-income people. To prevent big rate increases or fleeing from ACA markets because of
President Trump’s threat to cut off the funds.

39. California has, by far, the greatest stakes in the forthcoming battle
over whether ACA lives or dies.
Four years ago, when the ACA was in its infancy, California had fewer than eight million
residents covered by Medi-Cal. Today 13.5 million Californians, more than a third of the
state’s population, have Medi-Cal coverage, a 71% expansion since 2014, covering 48%
of all births and 23% of all seniors. In 2017 California will contribute about $1.3 billion to
its Medi-Cal expansion (5% of total cost), along with $17 billion from the federal
government. Rural counties with the state’s highest levels of unemployment and poverty,
have the most to lose.
The House GOP health bill would make 4-5 million Californians uninsured. The annual
funding loss to California in Medi-Cal and Covered California from the AHCA is over $24
billion–the same magnitude as what the state spends on all of higher education and all of
corrections, combined. The worst provision of many in the House bill would cap and cut
Medi-Cal which would not just eliminate the money for the expansion, but cap funding
for all 13.5 million Californians who depend on the program. ALL 14 of California’s
Republican Congressmembers voted for the AHCA. The rural counties with the highest
Medi-Cal enrollment rates are mostly represented by Republican congressional
members. Kevin McCarthy, the second-ranking Republican congressional leader, calls
Kern County where 50% of residents are on MediCal, home.

40. Kevin McCarthy, United States Congressman
House Majority Leader
mccarthyforcongress.com
(R-CA 23rd District) since 2014
Kevin Owen McCarthy is an American
congressman from Bakersfield, California.
He serves in the United States House of
Representatives for California's 23rd district.
Bakersfield is a city in California, United
States, and the county seat of Kern County.
California was recently ranked 1st among all states
for the total number of cases for chlamydia,
gonorrhea and syphilis by CDC. Kern County has
the highest reported increase in sexually
transmitted disease rates. At 42% higher than the
state average, Kern's chlamydia rate is the second
highest in California, just behind San Francisco.
Gonorrhea incidence rates in Kern County are 26%
higher than the state average. The rate increases for
syphilis in Kern are even more shocking. Kern's
syphilis incidence is 555% higher than
the state average, and third highest in California. The
prevalence of congenital syphilis, is 25 times higher
than it was 5 years ago. Kern's congenital syphilis
rates are the second highest in the state,
after Fresno County.

42. Californi
a
Darrell E. Issa
(CA-49) 37,700 29,200 44,900 52,400 69,700 73,100 307,000 51%
Californi
a
Duncan Hunter
(CA-50) 43,200 26,200 47,600 55,300 75,600 72,700 320,600 50%
Californi
a
Juan Vargas (CA-
51) 44,800 31,900 49,500 50,200 66,200 56,600 299,400 48%
Californi
a
Scott H. Peters
(CA-52) 35,300 29,800 61,400 60,800 73,400 69,000 329,600 51%
Californi
a
Susan A. Davis
(CA-53) 38,000 30,300 65,900 64,900 71,400 66,800 337,300 50%
State
Representative
(District)
Age 0 to 17
with Pre-
existing
Condition
Age 18 to 24
with Pre-
existing
Condition
Age 25 to 34
with Pre-
existing
Condition
Age 35 to 44
with Pre-
existing
Condition
Age 45 to 54
with Pre-
existing
Condition
Age 55 to 64
with Pre-
existing
Condition
Nonelderly
with Pre-
existing
Condition
Percent of
Nonelderly
with Pre-
existing
Condition

43. SINGLE PAYER
IS THE REAL ALTERNATIVE
(MEDICARE “2.0” FOR ALL)

44. SB 562, the Healthy California Act (Lara & Atkins), a bill that would guarantee healthcare
to every resident of California. Projected to save 18%
• The program would be in an independent state entity overseen by an unpaid board
appointed by legislators and the governor.
• Every resident of California, regardless of immigration status, is eligible.
* Choose any willing, licensed provider. No more narrow networks. No surprise bills.
* No out-of-pocket costs (premiums, co-pays, deductibles) for covered services.
* Eliminates co-pays for Medicare Part B.
* Lower prescription drug costs.
•Private health insurance companies limited to offering benefits and services that are
not covered by Healthy California.
• Financed by new 2.3% sales tax and 2.3% gross sales business tax
* Regional planning to reduce overlap and duplication of equipment and facilities.
* Provider payment rates which will replace and improve upon Medi-Cal rates, will be negotiated
to ensure access, cost control and high-value services.
•Huge cost-savings from reduced bureaucracy, approval and billing complexities. No more
insurance company runaround. No more bill collectors.
•* Depends on federal government waivers to divert $261 billion of federal dollars
currently sent to California to pay for Medicaid, Medicare, and the ACA, among other
programs. All money would be set aside in a trust fund. To cover everyone else who
has employer-provided insurance about $106.5 billion in premiums and out of pocket
expenses would have to be collected as tax revenue.(For context, the entire California
budget is $124 billion this year.)

47. Conyers HR 676
Expanded and Improved Medicare
for All “single payer national
health insurance”
• Automatic enrollment - everyone receives a
card assuring payment for all needed care
• Free choice of doctor and hospital
• Doctors and hospitals remain independent,
negotiate fees and budgets with public agency
• Public agency processes and pays bills
• Financed through progressive taxes

48. It was the best of times, it was the worst
of times, it was the age of wisdom, it was
the age of foolishness, it was the epoch
of belief, it was the epoch of incredulity,
it was the season of Light, it was the
season of Darkness, it was the spring of
hope, it was the winter of despair, we
had everything before us, we had nothing
before us, we were all going direct to
heaven, we were all going direct the
other way - in short, the period was so far
like the present period.
Charles Dickens, A Tale of Two Cities
English novelist (1812 - 1870)