On December 23, 2015, the United States Senate cast a final vote, 52–47, to repeal the Affordable Care Act. The repeal bill, proposed by Congressman Tom Price, was similar to bills proposed by Republicans on a regular basis since the Affordable Care Act became law in 2009. It intended to roll back the major measures of the Affordable Care Act, repealing the Medicaid expansion, removing the individual mandate, and drastically cutting the subsidy for private care. Price’s bill was vetoed by President Obama.
When the obstacle of the veto was removed on January 20 this year, Congressional Republicans were suddenly playing with live ammo: faced with the prospect of their bill becoming law, they were less than eager to rush a repeal bill to the president’s desk. The House Freedom Caucus, the Tea Party group in the House representing the right wing of the Republican Party, seemed to insist on nothing less than the 2015 bill. A handful of Senate Republicans, heeding the advice of several Republican governors, wanted to protect measures like the Medicaid expansion. And the president had more or less guaranteed perfect, universal, and inexpensive care. It was not clear that they could reach a compromise that would satisfy everyone, especially given the Republicans’ razor-thin margin in the Senate.
Whether or not the bill that House Republicans introduced on Monday will thread the needle is uncertain. It seems that even they are doubtful. This past weekend’s draft was kept under lock and key, safe from the prying eyes of the media, Senate Republicans such as Rand Paul (who spent his weekend spelunking in Congressional basement offices in pursuit of the Ark of the Covenant Bill), and the Congressional Budget Office (CBO). With Republicans hoping the bill will clear committee within the next two days, we will likely find out soon enough.
As the president recently learned for the first time, healthcare is quite complicated, but the basics of the bill are as follows:
- Begin phasing out the Medicaid expansion in 2020.
- Replace income and age-based subsidies with purely age-based subsidies, with the eligibility income cap for normal subsidies raised from $75,000 per year to $100,000 per year and with new smaller subsidies for high income individuals in the older age bands.
- Allow insurers to charge older customers five times as much as younger ones, an increase from the previous cap of three to one.
- Repeal the individual mandate, which fines people without insurance. Instead, introduce a “continuous coverage” rule: if a person loses coverage for more than two months, they are forced to pay thirty percent more when they repurchase health insurance for a full year.
- Expand tax breaks for employer-sponsored healthcare plans.
- Begin “block granting” Medicaid, with unclear implications for Medicaid’s long term funding levels.
- Defund Planned Parenthood.
The bill includes many other small provisions, such as the removal of caps on insurance company CEO pay and a surprisingly long provision regarding lottery winners. The thrust of the bill is that revenues are likely to decrease (the new continuous coverage mandate, unlike the Obamacare mandate, funds insurance companies and not the state) and subsidies will generally move to wealthier consumers.
This legislation is significantly more generous than the 2015 Price Bill, and has already been labelled “Obamacare 2.0” by Republican Congressman Justin Amash. The Republican Study Committee, a 172-member conservative caucus in the House, released a statement that was hardly enthusiastic, and some members of the Freedom Caucus were even more critical; former chair Jim Jordan called it “Obamacare by a different form.” Conversely, four vulnerable Republican senators have issued a statement expressing opposite concerns, asking for greater protection for the Medicaid expansion in several areas. It is easy to see why some Republican senators might be wary. Susan Collins, for example, represents Maine, the state with the oldest average age, where voters are unlikely to be happy about increased costs for older people who are still too young for Medicare. Republicans representing states that have expected Medicaid, such as Colorado Senator Cory Gardner, are also among the skeptics. A series of early morning tweets from the president (once again) complicated the situation, as Trump announced his full-throated support for the bill while simultaneously explaining that his beloved “getting rid of the lines around the states” provision would come in a “phase two” rollout. Staffers later corroborated Trump’s point, and explained that they would need a filibuster-proof sixty votes to get phase three through the Senate. The bill will receive no love from Democrats.
Moreover, the bill has yet to be “scored” by the CBO. At this point, it is not clear how much this bill will cost the federal government, and how many people are likely to lose coverage. House Republicans begin to plan marking up the bill on Wednesday, perhaps in an attempt to outrun the CBO.
Right out of the gate, Paul Ryan’s “American Health Care Act” is already beset by criticism on all sides. Whether or not it can gain support from across the Republican Party remains to be seen, and some powerful constituent advocacy groups like the AARP are already unhappy with many aspects of the bill. It is quite possible that Paul Ryan will have to go back to the drawing board, and that world famous detective Rand Paul will be forced to resume the hunt.