Somewhere on Capitol Hill, allegedly, there is a Republican bill to replace Obamacare. Lawmakers from both parties would love to see it. I would too, so I spent Thursday morning with them, chasing rumors of where it might be. Spoiler: We never found it.
Behind the scenes: four main components to ACA replace plan
While legislators crisscrossed the Capitol on a treasure hunt, a congressional aide gave me some details on how the much-rumored Obamacare replacement bill is shaping up.
There are two committees leading the work on a single bill, Energy and Commerce and Ways and Means. Both have jurisdiction over different parts of the health overhaul. They are preparing a bill that could pass through reconciliation, meaning it would only need 51 votes in the Senate. Importantly, that means Republicans would not need any Democratic support to move forward.
Reconciliation is a tricky process. The bill can only include changes that affect the federal budget. Right now it seems like there are four key policy proposals that show up in lots of Republican plans (such as Paul Ryan's A Better Way) that Republicans believe could move forward using this process. This is my analysis of those four proposals, shared by the Congressional aide:
- Expanding health savings accounts. Federal law currently caps how much patients can put in these tax-advantaged health care accounts at $3,400 for individuals and $6,750 for families. Most Republican plans would like to move those numbers upward to go as high as current out-of-pocket maximum limits ($6,550 for individuals, $13,100 for families). Republicans currently believe this could be accomplished in reconciliation.
- Tax credits. Nearly every Republican plan continues Obamacare-style tax credits to make health insurance more affordable. The Republican tax credits we've seen so far, however, are significantly less generous than those in the Affordable Care Act.
- Medicaid reform. There are lots of unknowns on what Medicaid reform will look like under a replacement bill. The most recent leaked draft would no longer provide a higher federal match rate for Medicaid expansion populations — but given all the pushback from Republican governors, it's easy to see that particular provision changing.
- Setting up high-risk pools. This would be a program to cover those with especially high-cost conditions, and shows up in numerous Republican health plans. How much funding will go toward these pools is the big question. Different bills floated over the past few years have ranged from $3 billion to $100 billion.
Scoop: New York Gov. Cuomo considers state-funded insurance subsidies
Staring down the possibility of Obamacare repeal, New York Gov. Andrew Cuomo (D) is considering dipping into state coffers to make sure residents of his state get the same financial help they currently receive.
New York is possibly one of the only states (alongside California) with a wealthy enough tax base to continue funding the insurance subsidies without federal help.
"We are very interested and working strategically to make sure that we take the necessary steps if the federal government does modify the structure of the tax credits," says Alphonso David, who serves as Cuomo's chief counsel.
In particular, David says they're closely watching Republican plans to change Obamacare's tax credit from an income-based subsidy (where low-income people get more help) to an age-based subsidy (where financial assistance is spread out evenly and low-income people don't get extra help).
"We think modifying the tax structure to penalize those who are unable to afford health care is nonsensical," David says. "To the extent Congress decides to adopt that approach, we are looking at various ways we can accommodate that change.
David added, somewhat proudly, "New York and California provide an extraordinarily large state tax base, compared to the rest of the country. I'll just leave my comments there."
Kliff’s Notes: Today’s top 3 health policy reads
- "Faring Better Than Many ACA Insurers, Molina Backs Health Law ‘Tuneup’": “Although some observers have criticized narrow insurance networks for not offering consumers enough choice, especially of medical specialists, having fewer doctors in the Molina Healthcare network has meant lower costs for the company and its customers. That means the health insurance company has been able to earn a modest profit — roughly 1 percent in the first couple years of Obamacare.” —April Dembosky, Kaiser Health News
- "High-Risk Pools Another Sticking Point Among Republicans": “Sen. Rand Paul on Wednesday expressed opposition to House GOP leaders’ plan to cover people with pre-existing conditions, highlighting another division that Republicans must overcome to repeal the Affordable Care Act. The Kentucky Republican said it doesn’t make 'logical sense' to allocate federal funds to help states run high-risk pools, which would be used to cover people who would be priced out of the marketplace if Obamacare is repealed. While dollar amounts haven’t been decided on, a leaked draft bill would divide $100 billion among the states over a decade to go to high-risk pools and other health care needs.” —Jon Reid, Morning Consult
- "Finance Committee approves Seema Verma for CMS chief": “The Senate Finance Committee approved Seema Verma's nomination as the administrator of the Center for Medicare and Medicaid Services on Thursday. She still has to be confirmed by the full Senate. It was a party-line vote.” —Caitlin Owens, Axios