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The problem every Obamacare repeal plan failed to solve

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Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

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Graham-Cassidy is dead for now. Senate Republican leaders made it official: There will be no vote this week. Never say never, but the repeal bubble has popped again.

Preexisting conditions again helped kill the beast. They have become the defining issue of the Obamacare repeal debate and maybe the most vexing problem for Republicans to solve. I think I finally fully appreciate why.

Back in December, before a word of the American Health Care Act had been written, a health care lobbyist reiterated a cardinal rule of Washington as we chatted over coffee: Once you give people a benefit, it's almost impossible to take it away.

Through most of the Obamacare repeal debate, I applied that wisdom to Medicaid expansion, to Obamacare's tax subsidies, to the millions of people who gained health coverage under the law. They were the benefits that would be hard for Republicans to roll back.

But now, after the issue of preexisting conditions has helped sink yet another Obamacare repeal plan, I think we can add the law's protections to the list of federal benefits that have proven unassailable.

This is the problem for Republicans: Under Obamacare, Americans know that health insurers can't deny them coverage or charge them higher premiums based on their medical history. No Republican plan could provide such an ironclad guarantee.

Obamacare's system does come with real trade-offs. Healthier people are asked to pay higher premiums than they would if insurers could give them a discount. Health plans have struggled in some places because the bills for the Obamacare customers were higher than they had expected. That is part of why we saw some significant premium hikes in the law's first few years.

But Republicans are yet to come up with an alternative that provides such certainty — and that they can sell to the American people.

An estimated 27 percent of Americans under 65 have preexisting conditions. The old days, when insurers in the individual market could discriminate against those people at will, are not forgotten. The "Jimmy Kimmel test" that dominated the final days of debate over Graham-Cassidy was founded on preexisting conditions.

People don't want to go back.

Now, there is a legitimate discussion to have about who should bear the cost of covering our sickest citizens. I think often about a pretty candid discussion I had with Sen. Ted Cruz (R-TX) on this issue.

Cruz authored a proposal that would have allowed insurers to offer skimpier, cheaper plans to healthy people while the federal government would cover the inevitably increasing costs for the more comprehensive coverage that sick people would still purchase.

“If those with serious illnesses are going to be subsidized, and there is widespread agreement in Congress that they are going to be subsidized, I think far better for that to happen from direct tax revenue rather than forcing a bunch of other people to pay much higher premiums,” Cruz told me.

It was, at the very least, an ideologically coherent argument, one that recognized the necessity of covering the cost of insurance for the most costly patients while shifting the burden from people paying premiums to the federal government.

But Cruz's proposal — like every other variation we've seen, including the state waivers in Graham-Cassidy — wasn't the same unimpeachable guarantee that Obamacare currently provides. It would have depended, for starters, on an unlimited federal commitment to pay the bills of people with high medical costs. It also didn't account for the unexpected emergencies that people inevitably face: If you're a healthier person with a skimpy plan, what happens when you get in a car accident?

Conservatives like Cruz would argue that of course the commitment would be kept. But that's not the same as a federal law stopping insurers from charging sick people more than healthy people.

Neither was Graham-Cassidy's system of state waivers, with the vague promise that states would provide "affordable and adequate" coverage to people with preexisting conditions. Outside health policy and legal experts were quickly able to punch holes in the bill's provision, no matter what its authors said.

The preexisting conditions benefit has now endured four different plans that could have rolled it back. When Sen. Susan Collins (R-ME) dealt the death blow to Graham-Cassidy Monday, this was clearly at the top of her mind.

The bill would "open the door for states to weaken protections for people with pre-existing conditions, such as asthma, cancer, heart disease, arthritis, and diabetes. Some states could allow higher premiums for individuals with pre-existing conditions, potentially making their insurance unaffordable," she said.

Most Republicans were able to reconcile themselves to undoing these protections. Check out this timeline from Talking Points Memo's Tierney Sneed to fully appreciate how far Republicans were willing to move, from agreeing that the protections should be kept to almost totally dismantling them.

But for Collins, like the vast majority of Americans, that was untenable.

And until Republicans win this argument, persuading the public and their colleagues there is another way, they could never truly repeal Obamacare.

Chart of the Day

The health risks of Puerto Rico's electricity outage. You've probably heard the news about the crisis in Puerto Rico, where parts of the island could be without power for months after Hurricane Maria. Vox's Julia Belluz walked through the health risks that come with such a prolonged power outage.

Kliff’s Notes

With research help from Caitlin Davis

Today's top news

  • “Senate Republicans pull plug on Graham-Cassidy Obamacare overhaul effort”: “Majority Leader Mitch McConnell, R-Ky., pulled the plug on the effort a day after a third Republican came out against the legislation, authored by Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La., which would have replaced Obamacare funding with a block grant system that would have let states control both the fate and funding of the embattled healthcare law.” —Susan Ferrechio, Washington Examiner
  • “CBO predicts ‘millions’ would lose coverage under the revised Senate health bill”: “The latest Senate Republican plan to tilt federal health-care law in a conservative direction would cause 'millions' of Americans to lose insurance by 2026, while lessening the federal deficit by at least $133 billion, according to much-anticipated estimates by Congress’s nonpartisan budget scorekeepers.” —Amy Goldstein, Washington Post
  • “With O’Care Repeal Dead Again, GOPers Cautiously Open To Bipartisan Talks”: “After Senate Republicans officially gave up on the Graham-Cassidy Obamacare repeal bill Tuesday afternoon, some Republican senators and members of leadership suddenly warmed to reopening bipartisan talks on a bill to stabilize the Affordable Care Act markets.” —Caitlin MacNeal, Talking Points Memo

Analysis and longer reads

  • “The Republican Senators Who Have Opposed the Many Bills to Repeal Obamacare”: “Republican leaders were trying to pass the bill in the Senate before the end of the month to protect it from a Democratic filibuster. They will now likely end the year without fulfilling their long-standing promise to repeal the health law.” —Wilson Andrews, Haeyoun Park, and Alicia Parlapiano, New York Times
  • “Will zombie Trumpcare ever truly die?”: “After promising for the better part of a decade to repeal and replace Obamacare, some Republicans aren’t ready to give up the dream, no matter how many costly setbacks they have suffered in the past eight months. Lawmakers are already discussing the possibility of going after an Obamacare repeal with the reconciliation tool by tying it to the G.O.P.’s tax-reform effort next year.” —Abigail Tracy, Vanity Fair
  • "The states spending the most out-of-pocket on health care":"Colorado's full of healthy hikers and mountain bikers, right? Well, it also has some of the highest out-of-pocket health care spending in the country. That's according to a report being released today by the JPMorgan Chase Institute, a new initiative that's using banking data to study spending trends and the financial pressures in people's lives." —Sam Baker, Axios

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