Senate leaders released their draft of a health-reform bill today, and you can go ahead and discount about half of the responses. By that I mean: If you believe there is always more money to be taxed from “the rich” and spent on government programs (which abso-definitely work just great, and very certainly, for sure, don’t result in a) Medicaid patients having trouble finding actual doctors who will see them, and b) Obamacare-plan consumers finally being able to afford premiums, only to learn they can’t afford their deductibles and are actually no better off) then you were not going to like anything a GOP Congress came up with. Period. Your version of health reform was tried, found lacking, and rejected at the ballot box in 2010, 2014 and, finally, 2016.
With that out of the way … the big question all along was whether Republican senators had the nerve to pass a bill that would try something very different from that approach. In the Democrats’ manichean view, there is only Obamacare or what existed before Obamacare; repealing and replacing Obamacare thus necessarily means going back to the status quo ante. This is one of many things they’re wrong about when it comes to health care. What existed before Obamacare was not “free market” health care. We haven’t had a free market in health care in decades, if ever. And let’s face it, a pure or maybe even predominantly free-market approach isn’t going to happen anytime soon, because the health-care market is so distorted at this point it’s hard to even know what that would look like. But a bill decisively more free-market in its approach would actually stand a chance of lowering costs (premiums and deductibles on the insurance side, and prices for services from providers) and eventually covering far more people.
Is that what we got?
Hard to say. The 142-page bill was just released a few hours ago, and it includes so many cross-references to existing statute that it’s difficult to immediately pin down everything it does. But here’s one first take from a Republican health analyst whose opinion I’ve come to value:
That’s a big statement from someone I don’t find to be prone to hyperbole.
One certainty is that it is not a pure repeal-and-replace bill. But we knew that going in: Reconciliation, the budget process the Senate is using on health care due to 100 percent Democratic opposition, has its limits. Because so much of what’s called “Obamacare” is actually federal regulation authorized by that law, much change will have to come through the regulatory process now led by Georgia’s Tom Price. What this bill can do is change taxation and spending.
It does the former in a much bigger way than the latter. The bill repeals a host of Obamacare taxes. It improves the tax treatment of important tools such as Health Savings Accounts and raises limits on contributions to them. Small businesses and their employees also appear to gain some important options in how they offer and buy health insurance.
As for spending, the subsidies for lower-income Americans are expanded down the income scale. They began at 100 percent of the federal poverty level (FPL) under Obamacare, which assumed everyone below that level would be covered by Medicaid, and ended at 400 percent. The new Senate bill instead offers subsidies via tax credits to everyone earning less than 350 percent. That’s more people on the lower end, but fewer people on the upper end (for reference, 350 percent of FPL this year starts at $42,210 for an individual and $86,100 for a family of four; 400 percent starts at $48,240 for an individual, $98,400 for a family of four).
Many of the bill’s changes to spending on programs such as Medicaid are phased in between 2021 and 2025. One supposes there are three reasons for this: to keep moderate Republicans on board, to postpone most of the changes until after the current president’s re-election campaign (a la Obamacare), and to provide some time for the market to adjust to the new realities the bill imposes. The bill seems to both anticipate and seek to mitigate growing pains.
But will people react to the stick while they’re still being fed carrots? Given all that has happened in the health-care market over the past decade, one could imagine providers, insurers and consumers alike being hesitant to make big changes, with the expectation that, as with Obamacare, things will change along the way — sometimes in large ways.
There’s a balance to be struck here between getting things moving and not having them move so quickly as to leave people feeling unsettled. That balance may not be just right in this bill. In fact, I expect that is where the more conservative senators will try to change things in the negotiations referenced here:
Those aren’t the stiffest of objections: “currently … not ready … open to negotiation …” And if there’s to be some stagecraft involved in this process, having the bill evolve a bit to assuage the conservatives’ concerns, rather than vice versa, is probably good politics for Mitch McConnell.
ADDED at 4:22 p.m.: And to the Republicans’ rescue comes … Barack Obama?
The former president, who didn’t have to deal with his predecessor sniping at him from the sidelines, weighed in on the Senate bill today with a lengthy Facebook post. It has all the use of strawmen and selective facts we came to expect from him. (Did you know Republicans “f[ought] for the Affordable Care Act for more than a year in the public square”? Because I don’t remember that.) He even cites the Congressional Budget Office’s analysis of the House bill in his rant against the Senate draft.
But where he really goes full-tilt progressivist — and possibly gives the GOP an argument, if they know how to recognize one — is when he writes: “The Senate bill, unveiled today, is … a massive transfer of wealth from middle-class and poor families to the richest people in America.”
This is an apparent article of faith on the left — you can find others writing the same thing — but it is truly through the looking glass. First, a “massive transfer of wealth” is explicitly what Obamacare was. Its entire purpose was to take money from some people (exactly whom, I’ll address in a moment) and spend it on others — namely, to help them purchase plans that a) doubled in price within four years; b) saw skyrocketing deductibles that undermined the economic value of having a plan for most of them; and c) continue to shrink in availability. The Senate bill undoes what Obamacare did, which is to say, it lets people keep their money rather than having it transferred to others. But to Obama, undoing that transfer is the transfer. Unbelievable.
Second, this transfer was from whom, exactly? I understand it is also an article of faith on the left that companies, not people, pay business taxes, but that simply isn’t true. Business taxes result in some combination of the following: less wealth for shareholders; lower wages for employees; higher prices for consumers. There is no fourth option. Perhaps Obama doesn’t care about the first of those, but the other two ought to matter. And consider what the taxes to be repealed cover (as they’re listed in the Senate bill):
- Repeal of the tax on employee health insurance premiums and health plan benefits
- Repeal of tax on over-the-counter medications
- Repeal of tax on health savings accounts
- Repeal of tax on prescription medications
- Repeal of medical device excise tax
- Repeal of health insurance tax
- Repeal of chronic care tax
- Repeal of Medicare tax increase
- Repeal of tanning tax
- Repeal of net investment tax
Of those 10, only the last could reasonably be construed to affect primarily high-income Americans — and even that requires us to ignore that many middle-income Americans also have investments. Otherwise, who pays OTC medications and prescription medications? Who buys medical devices and insurance? Who uses tanning beds? Not only, or even mostly, “the rich.” If Republicans are smart (big “if”) they’ll be happy to join this argument with the ex-president.