The long-awaited repeal of Obamacare can begin now that a curtain has risen to reveal the Republican replacement, but the audience is not happy. Some of this was to be expected; Democrats were never going to stand by and watch while Paul Ryan and Donald Trump dismantled what the Obama administration worked so hard to build. By Groundhog Day they had a catchy rallying cry and a headstart — Republicans were going to make America sick again — but nothing tangible to point at. It also meant the GOP did not have anything to placate intemperate crowds that filled town halls during a February recess, many convinced health care would be “taken away” from as many as 32 million Americans. Now Republicans are within reach of what, according to the House Speaker, “we’ve all been dreaming about” but the American Health Care Act is taking fire from Capitol Hill and a range of conservative activist groups who accept Rand Paul’s designation of the new bill as “Obamacare-lite.”
The most glaring reversal in a measure suffering from an apparently fractured identity involves the notorious individual mandate that helped awaken the Tea Party. It will live on, but take a new form: the IRS would be freed from the burden of collecting a penalty from tax refunds. When faced with consumers who go more than two months without coverage insurers will be required to hit the neglectful with a one-time 30% premium spike. Where the money goes is unclear, but the provision could be a way to salvage Obamacare’s mandate that people with pre-existing conditions can buy coverage. In a nod to conservatives, the GOP bill would effectively defund Obamacare’s Medicaid expansion by 2020, then install a “per capita cap” that would provide a fixed amount to each state for Medicaid. A number of unpopular taxes are also on the block, including those imposed on insurance carriers, medical device manufacturers, and higher payroll taxes aimed at high-income families.
Another sign of confusion and discord? The refundable tax credits in this replacement would essentially write a $2,000-$4,000 check to consumers who don’t get coverage through an employer. They’re means-tested, and thus are not available to individuals earning more than $75,000 annually, but since the credits are age-based they could leave low-income millennials paying for middle-class baby-boomer’s insurance. As a party the GOP is not sold on universal coverage, yet their bill includes this provision with a glimmer of intent to provide a different kind than Bernie Sanders would. Senate Democrats won’t be fooled, and their increasingly restive base would not stand for compromise if Paul Ryan included the credit as a hedge against potential Republican defections. It’s another sign the bill’s primary purpose is to fulfill a years-old campaign pledge.
Despite its faults, the Affordable Care Act had a mission: to provide universal insurance coverage by treating it as a public service with a set of “essential health benefits” and subsidies to bring new customers into the pool. All the while Republicans have spoken of insurance as a commodity whose prices can be tamed by introducing market forces like competition, while rightly pointing out the high deductibles associated with marketplace policies. The problem with relying on competition to hold down the cost of insurance and care is one of differing needs; people suffering from the flu or a muscle sprain can skip a trip to the local clinic and avoid a $20 co-pay. The most expensive kind of care — chronic and emergency — is not so easily subjected to a cost-benefit analysis.
As it stands the American Health Care Act looks like a turkey, and there are signs at both ends of Pennsylvania Avenue that Republicans know it. On Capitol Hill they hustled the bill through two committees in the middle of the night and intend to bring it before the full House in April after initially hiding it from lawmakers. At the White House Press Secretary Sean Spicer launched a pre-emptive strike on the Congressional Budget Office before its analysis, and all the bad news that came with it, went public. The president? Donald Trump is playing his part as a salesman, at one point telling the crowd at a Nashville rally last week that “the House legislation does so much for you,” but stumbled later during an interview with Fox News’ Tucker Carlson when Trump acknowledged his voters would be hurt by the same bill. The self-described “arbitrator” has one advantage over his comrades in Congress; he’s figured out how “complicated” health care is.
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