It can be hard to know which of President Trump’s tweets to take seriously sometimes, but evidently, his claim that the White House and Republicans in Congress are still working on health care reform after last month’s debacle with the American Health Care Act was true. According to The Washington Post, the White House is pressing an alternative version of the bill in an effort to win over both the hard right Freedom Caucus and the more moderate elements of the party, which combined to block a vote on the AHCA in March.
However, it’s unclear whether the measure being discussed will have much more success than its predecessor.
House Republicans found themselves in a bind two weeks ago when President Trump was demanding they vote to pass the extremely unpopular AHCA, a bill that had the support of about 17 percent of the country according to public opinion polls. It was unpopular largely because it would result in some 24 million Americans to be without health insurance within a decade -- 14 million by choice -- and would dramatically drive up costs for older Americans and the poor.
The Freedom Caucus was upset that the bill didn’t go far enough, demanding a rollback of multiple elements of the ACA that the bill didn’t touch, such as requirements that insurers not discriminate against people with pre-existing conditions and that they offer a suite of “essential” health benefits with every plan and more. Their object, above all, was to drive down the cost of insurance premiums.
House moderates, at the same time, were balking at the changes already in the AHCA, concerned that many fewer Americans would be insured and that costs would skyrocket for the poor and older Americans who were not yet eligible for Medicare.
The version of the bill now being considered would not solve those problems so much as avoid them. The plan would be to push decisions about issues like essential benefits and coverage requirements down to the state level.
For example, the proposal would allow states to drop the “community rating” requirement of the ACA, which demands that insurers charge the same amount for coverage for people who are the same age. In effect, this is a backdoor way of eliminating the ACA’s ban on discriminating against people with pre-existing conditions. While insurers would still be nominally required to offer policies to people with existing illnesses, there would be no limit on what they could charge them. Just as it was in the days before the ACA, sick people would be effectively priced out of the market for health insurance.
Similarly, the proposal would allow states to eliminate the ACA’s requirement that insurance policies purchased with government subsidies cover a set of standard benefits, including hospital stays, outpatient procedures, addiction and mental health treatment, maternity care, and more. The new plan would allow states to create a system in which people could use federal dollars to buy insurance plans that offer far less protection from health-related costs than the ACA requires.
This last move would create at least the possibility that states could achieve one of the key goals articulated by members of the Freedom Caucus: driving down average health insurance premiums. But it would do so in the same way that removing the requirement that new cars have brakes and airbags would make automobiles more affordable.
The hope among supporters of the plan is that by allowing the sale of bare-bones policies, the change would reduce the number of people who lose coverage under the new rules. However, it’s not clear that the Congressional Budget Office and the Congressional Joint Committee on Taxation would be willing to play ball when they score the bill. Last year, the CBO made it plain that for purposes of analyzing the effects of healthcare legislation, it would not consider people “covered” by insurance unless they were substantially protected from major financial risks.
The upside of this plan, from the perspective of the White House and Congressional Republicans, is that it would allow them to claim that they have kept their promise to repeal and replace the Affordable Care Act while avoiding the hard work of crafting a measure that solves the thorny problems that repealing the bill creates.
As with the original version of the AHCA, Republicans in the House can’t count on getting any Democratic votes for this iteration of the ACA replacement plan. So, assuming the changes are sufficient to win over the Freedom Caucus, the big question is the reaction of the more moderate members of the Republican conference.
Will the fig leaf of devolving key decisions to the states be enough political cover, or will the latest attempt to repeal the ACA cause another fracture in the party, albeit along a different fault line?