Obamacare has some real problems.
Republicans know this, and when Democrats aren’t on defense, they admit it too.
No, the Affordable Care Act isn’t “collapsing” everywhere — not even close — but in certain areas, it really is badly troubled, and is in danger of leaving consumers with zero choices on the individual markets. These problems are particularly evident in rural counties in Ohio, Tennessee, and Missouri, as Vox’s Sarah Kliff recently wrote.
Elsewhere, consumers are limited to one or two choices, or face deductibles that are far too high. These are legitimate problems that are in need of solutions, and members of Congress should try to fix them.
The problem is that Republican leaders’ health care bill isn’t actually designed to fix those problems.
Instead, the true purpose of the Senate’s Better Care Reconciliation Act — as with the House’s American Health Care Act before it — is largely to cut and restructure Medicaid, gigantically and permanently, so taxes can be cut primarily for the wealthy. Everything else is essentially an afterthought to that.
But there’s a better way.
Republican senators like Susan Collins (R-ME) and Dean Heller (R-NV) have already decreed that they’ll oppose a GOP health bill that causes tens of millions to lose insurance. If one more Republican senator joins them, Majority Leader Mitch McConnell will be short of the votes necessary to pass a bill.
Holdout GOP senators shouldn’t stop with opposition, though. They can — and should — demand a more serious attempt at fixing Obamacare’s flaws.
It is entirely possible to craft a health reform bill that leaves aside divisive issues like Medicaid cuts and tax cuts for the rich, and that isn’t projected to result in tens of millions more people ending up uninsured over the next decade.
This bill should instead focus on fixing the problems in the individual markets. Many Democratic senators would be willing and perhaps even eager to support such a bill. It could conceivably even meet President Donald Trump’s standards, since he has lately been pushing for Republicans to make their bill less “mean,” and did after all promise not to cut Medicaid.
All it would take is for three or more Republican senators to unite and demand such a bill.
They have the power — and they should use it.
It’s not enough to bemoan the process. Republicans who want to make health care affordable for their constituents should fight for a better, and fundamentally different, bill.
GOP leaders’ health reform bill isn’t a serious attempt to fix Obamacare
The primary focus of the Senate GOP health care bill is to cut hundreds of billions of dollars out of Medicaid, while also slashing hundreds of billions of dollars in taxes that primarily hit the wealthy.
The new CBO report makes that clear — in the breakdown of the bill’s changes to the budget deficit, the biggest items are $772 billion in Medicaid cuts subtracted from the deficit, and $541 billion in “noncoverage provisions” (a.k.a. tax cuts) added to the deficit:
Additionally, CBO projects that 22 million more people overall would end up uninsured by 2026 under the GOP bill than under current law — and in that time period, 15 million fewer people would have Medicaid compared to current law.
So the main action in the bill is very clearly about Medicaid cuts and tax cuts. And why is all that even necessary?
Now, the Senate bill does implement various changes to the individual insurance markets, too.
But the problem is that, according to CBO, it won’t even fix the problems Republicans have long identified in the Affordable Care Act:
- The bill won’t fulfill the promise Republicans have repeatedly made to their constituents that they’d lower deductibles. CBO projects that under the Republican proposal for the individual markets, premiums would eventually decrease, but deductibles would become so expensive for low-income people that “few low-income people would purchase any plan.”
- In spite of President Donald Trump’s repeated promise not to cut Medicaid, the Senate bill would cut $772 billion from it over the next 10 years. These cuts are entirely unnecessary for a bill supposedly aimed at fixing Obamacare’s individual insurance market problems.
- Furthermore, the bill wouldn’t even fix the problem of insurers pulling out of the individual marketplaces in certain areas. According to the CBO report, “a small fraction of the population resides in areas in which — because of this legislation, at least for some of the years after 2019 — no insurers would participate in the nongroup market or insurance would be offered only with very high premiums.”
Overall, then, it seems clear that the bill GOP leaders have offered up won’t actually solve Obamacare’s most serious problems.
So it’s high time for Republican senators to demand a bill that does.
Fix the individual marketplaces, and put aside conservatives’ dreams of Medicaid cuts
It’s long been clear that Democrats wouldn’t go along with Republicans in any serious effort to repeal all of Obamacare. That initially seemed to be a problem for any bipartisan deal.
But in fact, it’s become clear over the past few months that most Republicans don’t actually want to return to the pre-Obamacare status quo either.
Both the House bill and especially the Senate bill preserve much of the fundamental architecture of Obamacare’s individual insurance marketplace reforms. Specifically, they preserve the core idea that plans sold on the individual markets should be regulated in some way, and that many consumers should be offered subsidies to help them afford those plans.
The Senate’s bill is even closer to the Affordable Care Act’s architecture than the House’s. It preserves the concept of income-based subsidies, unlike the House bill, which pegged subsidies to age. And it includes a mechanism that would penalize those who didn’t purchase insurance. (They’d be forced to wait six months for coverage to kick in after they purchase it.)
All this is the case because enough Republican senators and Congress members made clear that they preferred policies that preserved much of Obamacare instead of full repeal — much to the chagrin of conservatives who want to fundamentally erase the Affordable Care Act.
Now that that area of overlap has become clear, key senators in both parties should go further. They should demand that the divisive and partisan issues of Medicaid cuts and tax cuts for the wealthy be put aside, in favor of a bill designed to fix the individual insurance markets where they need to be fixed.
Only then can an actual bipartisan legislative process aimed at fixing the Obamacare individual marketplaces’ flaws, and trying to make them actually work for all Americans, begin.
That process would try to make health insurance on the individual markets affordable where it currently isn’t affordable, and to ensure consumers have options in places where they are in danger of not having options. Sen. Lamar Alexander (R-TN) has some ideas for temporary fixes that could be a starting point for talks.
Why should swing senators like Lisa Murkowski (R-AK), Cory Gardner (R-CO), Rob Portman (R-OH), and Shelley Moore Capito (R-WV) hold their noses and support a horrendously unpopular bill that would gut Medicaid and cause hundreds of thousands of their constituents to end up uninsured?
They should instead join Collins and Heller in demanding that this flawed bill be dispensed with, in favor of trying to craft something better.
Not only does this have the potential to be good policy, it could also be good politics for Republicans fearful of running in President Trump’s first midterm elections. They could run as problem-solvers trying to do what Democrats couldn’t — fix Obamacare.