Up until now, the debate over the repeal and replace of the Affordable Care Act has been limited to the reading of tea leaves and, at best, educated guesses. We’re about to get some meaningful data. Earlier this month, House Speaker Paul Ryan promised that Republicans in the House would unveil their health care reform legislation after the mid-February Congressional break. And, in fact, details of the GOP leadership’s Obamacare replacement plan leaked today. (More on that, below).
The introduction of this GOP health care reform proposal is significant, but hardly as earth shattering as you might think based on the news coverage over the leak, let alone the attention the official unveiling will generate. Nor is this proposal necessarily indicative reflective of whats going to emerge from Congress at the end of this process. Think of it as allowing educated guesses to be a bit more educated. That’s important, but it determines nothing.
If you’re interested in what the 106-page document leaked today shows, Sarah Kliff of Vox.com has an excellent analysis. She writes that “In broad strokes, the draft bill hews closely to ideas outlined by House Speaker Paul Ryan and Health and Human Services Secretary Tom Price.” However, she does identify one “important shift” from earlier GOP proposals: “This bill … has more generous financial support for those who buy their own plans … and lower penalties for Americans who do not maintain continuous insurance coverage.”
Of course, the first question to ask is whether the leaked document is legitimate. The answer appears to be yes. There’s no bombshell that would suggest it’s only a trial balloon. It hews closely to the long-espoused reforms put forward by Republicans supporting high-risk pools, promoting HSAs and permitting health insurers to sell across state lines. Let’s assume, then, what we’re seeing today is exactly what Speaker Ryan will unveil next week. Does it matter?
Yes, but not much.
Changing America’s health care system will take time, regardless of how many politicians tell you otherwise. There are a lot of reasons why. Here’s just three:
- Republicans can’t agree on what they want to do. Just in the House of Representatives there a numerous factions each looking for a different outcome. The (very) conservative Freedom Caucus wants to repeal the entire ACA now and deal with a replacement later (if ever). Establishment members want to work out the replacement plan first and then simultaneously repeal and replace the ACA after a long transition period. Some of the two dozen members who represent districts that went for Hillary Clinton in the recent presidential election (and, I suspect, a percentage of those who endured raucous town hall meetings this week) seem more intent on repairing the ACA as opposed to blowing it up. Meanwhile, Republicans in the Senate can’t agree on what should follow the Affordable Care Act either. Many Senators, however, seem certain they don’t like the direction the House is taking. In short, consensus among Republicans is a long way off.
- Republicans need Democrats to replace the ACA. Even if Republicans reach a consensus on health care reform, they still need to bring along some Democrats to get the job done. Yes, heavy damage can be inflicted on the ACA through changes to the federal budget that require a simple majority of lawmakers in each chamber to pass. Regulations and executive orders can tear down more of it. Replacing the Affordable Care Act, however, will require at least 60 votes in the Senate (unless Republicans take the highly unlikely step of ending filibusters). With only 52 Republican Senators that means at least eight Democrats have to vote for the replacement legislation. And if Republicans factions in the House get too entrenched, the House Leadership may need some Democratic votes in that chamber to get anything passed. All of which means a lot of negotiating before there’s any hope of getting a new health care reform bill on President Donald Trump’s desk..
- The stakes are high–really, really high. As I’ve written previously, if Republicans get health care reform wrong they could destroy the individual health insurance marketplace. And I mean destroy. In fact, it may be too late to save the individual market (a possibility I’ll have another post on soon). Yet the GOP has been promising their base to nuke the Affordable Care Act and replace it with something better since before it was passed. Republicans need to act, but in a way that doesn’t leave their party explaining to voters why the demise of individual coverage is not Republicans’ fault.
Don’t get me wrong. That the GOP House leadership is introducing health care reform legislation is a meaningful milestone along the path to a post-Obama American health care system. If Secretary Price and President Trump sign-on to the bill, it will be a “big league” milestone. At the end of the day, however, it’s a milestone, not the finish line; just the first steps in what will be a long slog through numerous committees, endless public posturing, lobbying by interest groups, tumultuous public demonstrations, and intense negotiation. What Republicans are putting forward now may bear only a passing resemblance to what we get at slog’s end.
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