… this isn’t the bill.
The U.S. House today is expected to vote on the latest version of the American Health Care Act, a.k.a. the repeal-and-replace measure for Obamacare. It is slightly changed from the version that, almost six weeks ago, Speaker Paul Ryan put on ice for lack of support. If this version passes and moves on to the Senate, don’t get too hung up on the substantive differences between the two versions, because the key words here are “moves on to the Senate.”
The biggest mistake in this entire process was House leaders presenting their text as if it would be more or less the final legislation, and House members voicing their decisions to support or oppose it on the same premise. Because this bill will be subject to the Senate’s reconciliation process — which severely limits legislators’ options, but is a practical necessity due to Democrats’ insistence on filibustering a bill moving through regular order — the most important thing the House could do is get the bill over to the Senate. There, leadership can tweak the bill to fit the reconciliation rules, knowing that ultimately its compliance with the rules will be judged by the president of the Senate. Who, of course, is Vice President Mike Pence.
That’s been the refrain I’ve heard for some time from Republicans involved in the process. Why that isn’t how it played out in the House from the start, either publicly or privately, is hard to understand.
Nor has the House been particularly good about the one thing it should have been doing all along: Making the case for the big policy elements that are likely to stay in the final bill. For example, the different way this legislation treats those with pre-existing conditions.
The key point here — one that some of us made eight years ago during the original Obamacare debate — is that this is a relatively small population. It’s enough people, with a significant enough problem, that some accommodations need to be made. But it’s not enough people that the entire insurance system needed to be overhauled with a government mandate created for purchasing a private-market product, a drastic change to the economics of health insurance in the way of Obamacare’s “community rating,” and other market-rattling changes.
Obamacare tried to tackle this problem by requiring insurers to take anyone who applies regardless of health condition, preventing insurers from charging these consumers more than healthier ones, and imposing a significant yet insufficient financial penalty (or “tax,” but only when arguing before the Supreme Court) on the uninsured as a way of making them maintain insurance all along. It hasn’t worked. What has happened is younger, healthier consumers have stayed out of the insurance market, leading to higher premiums to cover the higher costs of the older and sicker consumers who did buy plans, leading to an even more skewed population in the risk pool, leading to even higher prices, and so on. Eventually this will hurt those with pre-existing conditions, too, because insurers will simply stop offering plans in areas where they’re bound to lose money. Indeed, that’s already happening.
A far better way to approach the problem of pre-existing conditions is to let insurers price coverage for those consumers appropriately and then use tax dollars to subsidize that coverage for those consumers. That keeps prices down for younger, healthier consumers, giving them more reason to buy plans. Done correctly, it should lead to falling prices — not just for the healthy, but for the sick as well. That means there should be less need for subsidizing those without pre-existing conditions, as Obamacare does to the tune of billions of dollars.
House Republicans have not made that argument well. But I’ll give Democrats credit, if that’s the right word: They know the above explanation is a lot harder to make than “We’ll make sure everyone with pre-existing conditions is covered!” — the economic realities be damned. Had another year or two passed, with Obamacare’s fundamental flaws becoming still more obvious, perhaps their B.S.* sales pitch wouldn’t have worked on as many people. But even if the politics of repeal and replace might have been easier a few years from now, time is also an enemy of reform. The longer people have even a flawed system, the harder it is to persuade them to accept a substantial change from it.
Time is also the GOP’s enemy in this respect: The longer it takes them to pass a bill, the more it appears — or Democrats can scream — they don’t know what they’re doing. They might have gotten away with it had they not promised such immediate action, but they did. Then they didn’t act in the knowledge that getting a bill — any bill — out of the House was more a procedural necessity than a substantive one.
Now I guess we’ll find out if late really is better than never.
*Relax … I meant “bumper sticker.”
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