Republicans would like Americans to believe they’ve come up with a kindlier, gentler way to repeal the Affordable Care Act. They haven’t.
The Senate on Thursday approved a GOP bill that would eliminate key elements of President Barack Obama’s signature domestic policy achievement, wiping out the coverage expansion that has produced a historic decline in the number of uninsured Americans.
The bill, which would also defund Planned Parenthood, moved through the “budget reconciliation” process. That meant it was not subject to filibuster and was able to pass with just 52 votes, more or less along party lines. The bill now goes to the House, where leaders have said they hope to consider and approve it before adjourning for the holidays late next week.
For House Republicans, repealing "Obamacare" has become a familiar exercise. They’ve voted to do so more than 50 times since early 2011, when the GOP first wrested control of the chamber away from then-Speaker Nancy Pelosi and the Democrats.
But Thursday’s vote was a first for the full Senate -- and that’s important, even though Obama has already said he’d veto the proposal. It’s a reminder that Republicans remain committed to repeal, even though it hasn’t figured prominently in the presidential campaign, and that they have lined up the necessary votes should one of their own become president in 2017.
Precisely because this is the first time the full Senate has taken up repeal, it’s also the first time Senate Republicans have confronted the trade-offs that such a change would entail -- including the potential political backlash.
Hating on Obamacare is a fine talking point, at least in conservative parts of the country. It’s also a great way to raise money from supporters. But millions of people are now getting health insurance through the program, including in states with Republican senators. (The Huffington Post’s Jeffrey Young recently calculated that 3 million of these people are on Medicaid alone.)
Quite a few of these Republican senators are up for re-election this year. Republicans from ultra-conservative states like Alabama or Utah may not sweat the political repercussions of cutting off Obamacare insurance. But Rob Portman faces a tough re-election fight in Ohio, a state that voted for Obama twice and in which hundreds of thousands of people are getting insurance through the program. Kelly Ayotte in New Hampshire, Pat Toomey in Pennsylvania, and several other Republicans face similar situations.
Before Thursday’s vote, GOP leaders told members not to worry, on the theory that Obama’s inevitable veto makes this something of a consequence-free vote anyway. But, as Politico has reported, Democrats are already planning ads to attack Republicans for voting to take away health insurance. That may help explain a major wrinkle in the Senate’s bill. Instead of cutting off insurance right away, as House repeal measures would have done, the Senate bill would allow key parts of the program’s coverage expansion to remain in place for two years.
For 24 months after enactment, the federal government would continue to finance the law’s expansion of Medicaid, making the government-run insurance program available to all people with incomes below or just above the poverty line, at least in the 30 states (plus the District of Columbia) that have chosen to participate in the program.
During this time, the Affordable Care Act’s insurance exchanges would also remain open for business. People unable get insurance through employers or other government programs could keep buying comprehensive coverage, no matter what their pre-existing conditions, and many would be eligible for the generous tax credits that discount premiums by as much as thousands of dollars a year.
Sen. Shelley Moore Capito (R-W.Va.), who had previously expressed misgivings about yanking insurance from her constituents, explained the logic of the extension earlier this week. “It’s a two-year transitional period to move to a replacement vehicle so we can come up with a better plan,” she told The Hill. She summed up the feelings of her caucus by saying, “We feel pretty good.”
But there are lots of reasons to question the GOP’s commitment to making sure its constituents can hold onto insurance. One is that the Senate bill would appear to make some changes immediately -- among them, zeroing out the penalties that go with individual mandate. Without those penalties in place, premiums would likely rise, to the point of causing real problems in the exchanges.
Another reason is that Republicans have been promising to rally around an alternative scheme pretty much since the Affordable Care Act became law. They haven’t done so yet -- and it’s no great mystery why.
Health care policy can seem complicated but, stripped to the essentials, it’s pretty simple. People who are sick need medical care. That medical care costs money, more than most individuals can pay at any one time. Universal coverage schemes, including Medicare, solve this problem by spreading the financial burden widely -- in effect, transferring money from rich to poor and from healthy to sick. Insurance plans that large corporations offer employees work on similar principles. The Affordable Care Act is an effort to create a similar scheme for the rest of the population.
Conservatives say this is “redistribution.” They are correct. The redistribution from rich to poor is why taxes on the very wealthy went up, and Medicare started paying parts of the health care industry less, when the Affordable Care Act became law. The redistribution from healthy to sick is why some people, mostly young and healthy people whose old coverage didn’t cover as many benefits, must pay more for insurance than they did before the law took effect.
Conservatives boast that repealing the Affordable Care Act would undo these changes -- so that young and healthy people could have access to cheap health insurance again, insurers would be free to sell skimpier policies, and taxes would come back down. Conservative are correct about this, too.
But these changes would have repercussions. If the young and healthy pay less, then the old and sick will have to pay more -- a fact the young and healthy will learn eventually, once they are the ones who are old and sick. Loosen or eliminate requirements on insurance benefits and the people who need coverage for mental illness, or rehabilitative services, or having a baby may have a hard time finding coverage. Reduce or take away subsidies for the poor and middle class and far fewer will be able to pay for comprehensive coverage.
This is why the reform proposals that circulating among conservatives and Republicans would almost certainly result in some combination of significantly fewer people insured and significantly less protection for people who have insurance.
Republicans haven’t closed ranks behind one of these proposals, perhaps because doing so would mean acknowledging and defending the results. But voting for a repeal bill with no replacement would mean voting to take health insurance away from tens of millions of people, all in one fell swoop.
Matt Bevin, the newly elected Republican governor of Kentucky, has already discovered how tricky this could be. As a candidate, he frequently vowed to roll back the state’s Medicaid expansion. But lately he has suggested he’d settle for merely modifying the program, because taking insurance away from so many of his constituents would be so traumatic.
The two-year extension in the Senate bill represents another way of trying to deal with this problem. It’s an attempt to disguise the true impact of repeal. Whether Republicans get away with it depends, in no small part, on whether the voters see through the ruse -- and remember it when they vote in November.
This article has been updated to reflect Thursday's Senate vote.