Readers know I’ve been deeply engaged in the healthcare debate, and highly critical of the efforts thus far to repeal and replace, demean and deface, disgust and disgrace, etc.
But I haven’t weighed in on up to the minute changes in part because they’re changing fast and because the journalists who follow this are doing a good job of tracking developments in the Senate.
In sum, Senate R’s have failed to pass any of the repeal and/or replace bills they’ve come up with so far. At this point, McConnell looks to be counting on getting to 50 votes with “skinny repeal,” which gets rid of the individual and employer mandates, along with a tax on medical devices.
At one level, this is high strategery. His play is to get to conference, i.e., once both chambers have passed bills, the R’s convene a committee that tries to agree on a plan that R majorities in both houses will support. There’s no requirement that what comes out of conference looks like what went in, and that means they’re most likely to go right back to the full, draconian repeal-and-replace cuts that would lead to tens of millions losing coverage.
Would Senate “moderates” who’ve blocked these bills thus far backtrack and vote for stuff they’ve heretofore opposed, like huge cuts to Medicaid or ending coverage of pre-existing conditions, maternal care, mental health, substance abuse treatment, etc.? They might, but it’s worth remembering that the debate on the conference bill is constrained, no amendments are allowed, and leadership will be in full arm-twisting mode.
People are calling the skinny repeal a Trojan Horse but it’s really more of a stalking horse. The Trojan Horse was supposed to be something good on the outside with something bad on the inside. But this damn thing is just all bad.
In fact, the skinny repeal should make even less sense to Republican voters (and yes, I know that trying to make sense out of any of this is a waste of time). While the Medicaid expansion has proven to be extremely important in expanding affordable coverage, the part of Obamacare that conservatives have consistently screamed the most about is the alleged collapsing of the non-group market.
After a few years of the experience with the ACA, private insurers are figuring out how to profitably price coverage. But many moving parts make this process an ongoing challenge for them. Some of that was expected, like the phaseout of reinsurance subsidies. But others, like the Trump administration’s flirting with the loss of cost-sharing subsidies that private insurers depend on to hold down premium charges, are pure sabotage.
These payments reduce deductibles and copays for low- and moderate-income people, and their loss could lead the average premium for a benchmark plan to go up almost 20 percent. Just as they’re getting the pricing calibrated, the uncertainty around whether the government will continue to make these payments has surfaced as one of the main reasons that private insurers are asking themselves whether it makes sense to continue to offer coverage in the exchanges.
Let’s pause on the irony here for a moment. Conservatives’ flawed ideology (explained below) that the private sector is the most efficient delivery mechanism for health coverage kept a public option out of the ACA. But the private insurers themselves said at the time, and maintain to this day, that they can’t serve the exchanges without government subsidies. Now, Republicans want to block those subsidies, because … you guessed it … the private market blah, blah, yada, yada.
To pile irony on top of irony, the skinny repeal doesn’t go after Medicaid, but it’s a great tool to further destabilize the non-group market. Once you end the mandates, you invite the adverse selection that undermines risk pooling. Healthy people opt out, leaving more expensive people behind. Premium rise–2o%, according to CBO–leading the next healthiest tier to leave, and so on (the budget office also predicts this plan will leave 16 million fewer people with health coverage).
Which is why, according to the Times, Blue Cross Blue Shield warned senators “against repealing the mandate that almost everyone have insurance without something to take its place.”
BTW, depending on how much of the rest of the ACA remains intact, higher premium subsidies will help many consumers offset these higher coverage costs, meaning not only will skinny repeal cover fewer people at higher costs, but the government will have to make up some of the difference. Great work, R’s!
Given the just plain mean and ill-founded hostility of Republicans towards the poor and Medicaid, I at least understood their motive for the deep cuts they proposed (supported by Trump, who lied about this in the campaign, promising not to cut the program). Yet now, they’re tactically stripping down their repeal plans down to parts that exclusively make purchasing health care in the private marketplace a lot more expensive, the very thing they’ve whined about for years.
I know I should be totally used to it by now, but I’m still taken aback by the hypocrisy of these politicians, and by their willful failure to try to meet the needs of anyone who isn’t one of their rich donors.