The the vice president casting the tie breaking vote, the Senate voted 51- 50 to debate the repeal and replace of the Affordable Care Act. But just what are they debating?
The plan emerging in the hours before the successful vote was for the Senate to vote in the days to come on competing repeal-and-replace plans which lack the votes for passage, before ultimately landing on what is unfortunately being termed “skinny repeal.” The idea is to pass the barest of repeal bills through the Senate in hopes of sending the repeal effort to a conference committee with the House-passed replacement bill, where a final deal can be hashed.
The fact that Senate Republicans sought to move forward with the Obamacare repeal effort without a robust replacement plan, or even a comprehensive repeal bill, ready to pass comes after months of frenzied negotiations that fell short this week. For seven years Republicans ran on repealing and-replacing the Affordable Care Act during which they never settled on a consensus replacement. The disagreements on health care reform that divide the GOP conference had not been solved when Senate Republicans voted Tuesday to move forward anyway.
They will now move onto a few days of floor debate on the effort that will also bring a series of votes on amendments related to the yet-to-be-determined health care bill.
That Republicans would subject themselves to this politically ugly process that may fail in the end reflects the immense pressure GOP senators were under from President Trump and conservative groups not to abandon what appeared to be a doomed effort just a few days ago. [..]
GOP leaders kept members in the dark of what bill they would be voting to proceed to in the hours before they voted Tuesday. The “skinny repeal” that emerged as a possible plan Tuesday morning would be a narrow set of repeal proposals that Republicans mostly agree on. If it became law, it would almost certainly torpedo the individual market in some places and make worse the health care problems Republicans complained about under Obamacare.
By the end of this week, Republicans will likely get to vote on whether they are willing to pass that option out of Senate to keep the repeal dreams alive for the next legislative step.
The “skinny repeal” would eliminate three of the ACA’s least popular provisions among Republicans: individual mandate, the employer mandate and a tax on medical devices. But as Margot Sanger-Katz at the New York Times points out, there’s an up side and a down side:
The upside of such a plan: Those provisions are unloved. The individual mandate forces Americans who go without health insurance to pay a tax penalty. The employer mandate subjects businesses to a lot of paperwork requirements. The medical device tax hits an industry that has lobbying pull with many Republicans and even many liberal Democrats. A plan that eliminated only these three parts might be plausibly sold as Obamacare repeal, and it would avoid many of the more controversial policy changes in other G.O.P. proposals. [..]
But, of course, there is a downside.
The individual mandate is unloved because no one likes being told what to do. But many independent analysts have concluded that, without a mandate, health insurance would become more expensive and cover fewer people. With the nudge of a mandate, more healthy people tend to buy insurance, reducing the average cost of coverage. Without one, the theory goes, mostly sick people buy insurance, and premiums rise to cover that sicker pool.
Fewer people would probably be covered under Medicaid, too. Over the last few years, signups for Medicaid have increased substantially, even among people who could have been covered before Obamacare expanded eligibility. Many of those people presumably didn’t realize they qualified for Medicaid and first tried to buy private insurance because of the mandate, before learning that they could get Medicaid and not have to pay a premium. Without a mandate, fewer people are likely to find their way into the program. [..]
The Congressional Budget Office thinks that eliminating the individual mandate would have substantial negative effects on the insurance market, raising prices and reducing enrollment. It is hard to imagine that more insurers would wish to participate in this smaller, sicker market. The budget office still needs to evaluate a skinny repeal bill, but it seems likely that the reductions in coverage from a mandate repeal would save the federal government enough money for the bill to comply with budget instructions.
It is worth considering these effects in the context of Republicans’ criticisms of Obamacare itself. On the Senate floor Tuesday, Mr. McConnell assailed the health law as building unstable insurance markets and providing too little consumer choice. A skinny repeal would probably exacerbate those effects.
Sanger-Katz also notes that all but one of the Republican despised taxes would remain as would all of the regulations on insurance companies they are eager to repeal. The “skinny repeal” also leaves Medicaid as it is, including the ACA expansion. This may or may not meet the Byrd Rule test or satisfy the hard core right that wants the ACA repealed. If passed in the Senate, it may not get the votes in the House where the hard right minority rules the roost. This is going to be a long week.