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The day tax reform became Obamacare repeal

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Obamacare's individual mandate can't catch a break.

The requirement that all Americans purchase health insurance was at the center of the first major battle over the Affordable Care Act: a Supreme Court case over whether it was legal to mandate the purchase of private health insurance.

The individual mandate survived that battle but now is at the center of another big fight, this one about tax reform. We learned late yesterday that Senate Republicans intend to add a repeal of the individual mandate to their tax bill.

There are two key reasons to do this.

First, repealing the mandate saves the government money. The Congressional Budget Office estimates that not requiring Americans to carry health insurance coverage would reduce the deficit by $316 billion over the next decade. (This is mostly because fewer people would participate in government health insurance programs, so less money would flow to subsidizing those programs.)

As Vox's Dylan Matthews and Tara Golshan write, the individual mandate repeal and other changes were made to the Senate tax bill to "ensure the new plan complies with the 'Byrd rule' of Senate procedure. Senators can’t pass legislation that increases the long-run (traditionally defined as 10-plus years into the future) deficit through the budget reconciliation process, a process that enables senators to evade the filibuster and pass bills with only 51 votes (or 50 plus Mike Pence)."

Repealing the individual mandate creates more space to pursue larger tax cuts in this current reform effort.

Second, the individual mandate is unpopular. The Kaiser Family Foundation released a new poll Wednesday finding that 55 percent of Americans support the idea of repealing the individual mandate.

That number rises to 73 percent when you look at the respondents who identify as Republican.

What's more, the individual mandate often polls as the most unpopular part of Obamacare. The law's ban on preexisting conditions and requiring insurers to cover young adults on their parents' plans through age 26 typically get high marks. But it's notable that even 38 percent of Democrats in the Kaiser poll say they'd be supportive of repealing the individual mandate.

Charging Americans a fine for not buying health insurance, unsurprisingly, isn't a big political winner.

But this doesn't mean the politics of individual mandate repeal are easy. Repealing the individual mandate isn't a standalone decision. Multiple analyses expect that premiums would increase and millions would lose coverage if this part of Obamacare went away.

The reason is clear: When there isn't a requirement to purchase health coverage, those with few health conditions may decide to skip insurance. They would leave the market, not paying premiums if not required to do so.

This would leave a sicker population behind. Those people would end up with higher premiums. Some of the people who did want insurance would ultimately get priced out of the market as premiums rise higher and higher.

The Congressional Budget Office estimates that 13 million Americans would lose coverage if Congress repealed the individual mandate. That figure actually does a lot to sway public opinion about whether repeal is a good idea.

The Kaiser poll shows what happens when people are asked whether individuals support repealing the individual mandate. They then followed up with a second question, about whether their opinion would change if they heard that it would increase the number of people without health insurance by 13 million over the next year.

Support for mandate repeal dropped by 17 percentage points after hearing that fact.

This has always been the challenge of individual mandate repeal for Republicans. While the idea polls well initially, it has real-world consequences. Headlines about millions of Americans losing health insurance are really hard to contend with — as we saw in the Obamacare repeal fight earlier this year.

But you can't separate the two. Repealing the individual mandate has big consequences, and Republicans will need to decide if they are ready to face them.

Chart of the Day

Lori Lodes/Get America Covered

Obamacare sign-ups are strong two weeks into enrollment period. New data from the Trump administration shows that 1.5 million Americans have signed up for Affordable Care Act plans. The pace of enrollment continues to move faster than the past two open enrollment periods, as this table from Get Covered America shows. This open enrollment (OE5, on the left) has averaged 134,386 daily sign-ups so far. Last year at this point, Obamacare had a daily average of 84,018 enrollments.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

News of the day

  • “Health Groups Balk at Obamacare Being Dragged Into Tax Debate”: “Eliminating the mandate “will result in a significant increase in premiums, which would in turn substantially increase the number of uninsured Americans,” the groups said in the letter. The groups include America’s Health Insurance Plans, the American Medical Association and the American Hospital Association.” —Anna Edney, Bloomberg
  • “Hurricane Damage To Manufacturers In Puerto Rico Affects Mainland Hospitals, Too”: “The storm damaged many of the island's more than 100 drug and medical device manufacturers. Puerto Rico produces about $40 billion worth of pharmaceuticals for the U.S. market, according to the Food and Drug Administration — more than any other state or territory.” —Alison Kodjak, NPR

Analysis and longer reads

  • “Why We’re Still Fighting Over the Health Care Mandate”: “Why has the mandate become so central to our politics? And why has the debate about it persisted with such intensity? To answer those questions, it helps to understand how its supporters and opponents view the provision.” —Peter Suderman, New York Times
  • “How The CBO Drove Obamacare's Individual Mandate Repeal Into Tax Reform”: “The single most important reason that Republicans failed to replace Obamacare in 2017 is because of estimates by the Congressional Budget Office that 22 million fewer people would have health insurance in 2026 under the GOP bills. But CBO went out of its way to avoid pointing out that the vast majority of the coverage difference was due to one feature in the GOP bills: their repeal of Obamacare’s individual mandate.” —Avik Roy, Forbes
  • “HHS Pick at Odds With Trump’s Rhetoric on Drug Prices”: “Eli Lilly is a major producer of insulin for diabetes treatment, and many have questioned the rising prices in that category. Prices of Lilly’s drug Humalog jumped from around $100 in 2010 to more than $250 in 2016, according to a report from the Congressional Diabetes Caucus. Lilly and several other companies that make insulin face several lawsuits claiming that they colluded to jack up insulin prices.” —Andrew Siddons, Roll Call
  • “The Road To Affordability: How Collaborating At The Community Level Can Reduce Costs, Improve Care, And Spread Best Practices”: “Despite all we heard about deductibles and bronze versus silver plans, the debate in Washington was focused on the wrong thing. We can’t have affordable insurance until we have affordable health care, and we won’t have affordable health care until we address the drivers of rising health care costs.” —Elizabeth Mitchell, Health Affairs

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