GOP dog catches the health-care car
The Republicans have finally rolled out their replacement for the Affordable Care Act, but the long-awaited health care fix may need some immediate resuscitation efforts.
Opposition from conservative Republicans in the House coupled with balking by moderate GOP senators could spell doom for the Obamacare replacement offered by House Speaker Paul Ryan. The bill is either too much or too little like the current law, depending on which side of the Republican caucus is talking.
The National Review’s Michael Tanner calls it “political malpractice in action,” saying Ryan and company have “managed to botch both the politics and policy” of the moment.
Rather than go all-in with a market-based approach, he says, “the Republican plan is essentially an effort to split the health-care baby in two.” That’s because, after Republicans pounded away at the Affordable Care Act for years, there are elements of it that more moderate Republicans are not now going to be willing to throw overboard.
Just to zero in on one central issue, the Republican plan seems to twist itself in knots over the issue of an individual mandate, which was once a cornerstone of conservative thinking, birthed by a Heritage Foundation plan that Mitt Romney then ran with in fashioning the 2006 Massachusetts law that become the foundation for Obamacare.
Requiring everyone to purchase insurance — rather than become costly free-riders should they face a high-cost condition for which others would be forced to pick up the tab — was put forward under the banner of “individual responsibility,” not as some crushing nanny-state edict.
It was considered a necessary companion to Obamacare’s provision against denying coverage to people with preexisting health conditions, because it would expand the insurance pool to include lots of healthy people and ensure that people don’t sign up for insurance only at the point when they need it.
The preexisting condition provision is incredibly popular with the public, and the GOP plan keeps it in place. But with the individual mandate having morphed from Heritage Foundation policy point to Freedom Caucus heresy, the plan dumps the mandate but tries to backdoor its way to the same outcome. The bill replaces the mandate with tax credits to spur people to buy coverage, and it allows insurers to charge those who let their coverage lapse for more than 63 days a 30 percent surcharge on premiums to renew coverage.
But many on the right say it won’t work. Avik Roy, a leading conservative policy thinker who has served as an adviser to Marco Rubio, Rick Perry, and Mitt Romney, says the incentive structure won’t deliver and that healthy people will eschew coverage, while sick people will be willing to pay the 30 percent surcharge in order to sign up to cover very costly care. He calls it a “recipe for adverse selection death spirals” — meaning the individual market will crash as it is increasingly dominated by high-utilization patients whose costs drive premium prices to unsustainable levels.
“This is the plan,” President Trump declared yesterday as he offered his backing to the House bill. “It’s a complicated process, but actually it’s very simple, it’s called good health care,” he said with his trademark breezy certainty.
But looking to stem the rebellion from Republicans who called the bill “Obamacare lite,” Vice President Mike Pence called it only the “framework for reform,” while Health and Human Services Secretary Tom Price, in a briefing yesterday with reporters, referred twice to the legislation as a “work in progress.”
Trump is more performance artist than policy purist, and he often seems more concerned with the optics of a plan than with with its operation and actual effect. He’s a guy with a strong appreciation for Marxist ideology — that is, Groucho Marx’s view on unbreakable beliefs: “Those are my principles, and if you don’t like them…well, I have others.”
Trump is about the art of the deal, and is looking for a bill signing moment where he can declare that Obama’s disastrous law has been replaced with something really beautiful. He’s probably frustrated that everyone is getting caught up in all the details.
House Speaker Ryan pronounced yesterday, “The nightmare of Obamacare is about to end.”
But the declaration underscores the Republicans’ main problem: They have been far more fixated on demonizing Obama’s signature domestic legacy than on carefully crafting something that can win broad public and political support to put in its place.
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