Health care legislating ain’t pretty. In many cases, it’s downright coyote ugly. Particularly in the absence of a coherent and consistent majority in favor of substantially revising the status quo. Hence, today’s Senate Republican leadership “discussion draft” bill.
To be fair, leaders can’t go where they don’t have enough followers. So a good bit of today’s exaggerated reactions on the Right involves failure to come to terms with the divergence between past feel-better rhetoric and today’s grimmer political realities. There are neither enough votes nor popular support to repeal Obamacare simplistically, or engineer a softer landing toward substantial reform of the ACA — let alone offer a long-term path toward market-based health policy in practice. A long parade of mistakes in politics and policy were made AFTER March 2010 that helped deliver us to today’s limited set of legislative options.
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To estimate the impact of the AHCA, the CBO had to compare it to predictions of coverage under the current law, the ACA. If the prediction for the current law is incorrect the prediction of lost coverage will be too.Yet the CBO has consistently overestimated future ACA coverage gains. In 2012 it predicted an additional 28 million would gain health insurance by 2017. The actual figure is 20 million. It forecast 25 million would gain coverage on the ACA exchanges and 10 million would gain Medicaid coverage. Less than half as many actually enrolled on the exchanges and not all of them gained coverage – many were replacing non-exchange policies they lost after ACA passage. Conversely, about 14 million – 40 percent higher than predicted – newly enrolled in Medicaid. The CBO prediction that 5 million would lose employer coverage was also wrong – employer provided coverage was stable.
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Employers and other private purchasers of medical services have played an important role in spurring health care delivery system and payment reform. The development of managed care has been accelerated by federal and state policies over the years but originated with private sector purchasers. Other models, such as accountable care organizations and bundled payments, were initially designed by employers seeking to improve value in the coverage they offered to their employees. These models are now being used to improve quality and lower costs in Medicare and Medicaid.
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The Senate GOP will need to produce a bill that can claim to have significantly changed Obamacare, achieve at least the same amount of cost savings as the House bill did through the budgetary reconciliation process, and that will be able to garner support in both the Senate and the House. The Senate will also need to fix the simple fact that the age-adjusted, fixed-dollar tax credits to subsidize insurance coverage in the AHCA are too simple and insensitive to the income-related health needs of lower income Americans.
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The three latest theatrical gambits to fan the smoldering embers of the previously-abandoned AHCA include: 1. The cost-sharing subsidy payment termination bluff, 2. Grasping for the thinly-funded straw of “invisible” risk pools to promise individual insurance market premium reductions and protection of coverage for persons with pre-existing health conditions, and 3. The Freedom Caucus “lions” are preparing to lie down with the Tuesday Club “lambs” in a new compromise that revives an amended version of the AHCA.
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The shaky case for the individual mandate is based on mistaken premises, faulty economic analysis, short-sighted politics, and flawed health policy. Opponents have found the mandate to be administratively challenging, politically unsustainable, economically unnecessary, beyond the proper role of government, and constitutionally questionable. Arguments in favor of the individual mandate usually present it as a necessary, though far less popular, means to more laudable ends.
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The attempted imposition of the notorious Obama-era “HHS mandate” on religious organizations, especially Catholic institutions, reflected an attitude that has been pervasive during Obama’s presidency, which is one of barely concealed hostility toward persons or organizations holding on to traditional religious beliefs. It should be the first order of business of the incoming Trump administration to rid the federal government of this attitude and the associated policies that flow from it.
The place to begin that process is with the HHS mandate itself. The mandate is a rule, finalized initially in 2013, that requires nearly all employers in the United States to provide all manner of free contraception in their health-plan offerings. The Obama administration went out of its way to impose this requirement even on many Catholic institutions, such as universities and hospitals, knowing full well that the requirement violated fundamental teachings of the church. It then provided only the narrowest of exemptions to the general requirement and fought every legal challenge trying to provide greater latitude to religious organizations or employers with religious sensibilities.
James, C. Capretta, resident fellow at the American Enterprise Institute and health care policy scholar, answers questions about why Obamacare isn’t working and how those on left and the right aim to alter the health care law. Capretta says, “[Republicans want to] retain the employer-based health insurance system and change the structure of the regulations involving the non-group market that’s now covered by the ACA. They’d have subsidies, tax credits for people outside the employer system to make sure everybody in the United States could get health insurance if they wanted it. This mirrors a proposal that was introduced a couple of years ago by Senator Hatch, Senator Burr, and Congressman Fred Upton. That plan looks a lot like a House’s “Better Way” health care plan. I would say that the leading contender for what would be a replace is somewhere in the universe of those two types of plans.”
Beginning in January, the Republican-controlled Congress, working with the incoming Trump administration, will have the opportunity to roll back the Affordable Care Act and replace it with a plan that is less driven by federal control and regulation. The starting point for this effort ought to be that everyone in the United States should have health insurance, protecting them against major medical expenses. To do so, the GOP should:
- Grandfather Coverage Provided by the ACA
- Accept and Clarify Medicaid’s Role as the Safety Net Health Insurance Program
- Impose Cost-Discipline and Generate Revenue with an Upper Limit on the Tax Preference for Employer-Paid Premiums
- Build an Effective Auto-Enrollment Program to Achieve Higher Levels of Coverage
The GOP Congress and incoming Trump administration will need to make some decisions in the coming weeks on how to proceed with a legislative agenda in 2017. The course they choose to take is likely to define the rest of the Trump presidency, just as decisions President-elect Obama made in late 2008 and early 2009 — to do a large stimulus bill first, followed by a sweeping health care law, and then Dodd-Frank — came to define his presidency.
Based on press reports, it seems the GOP is about to choose a path that will haunt them for years to come.
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