For the last several years, the GOP has been determined to undo all things Obamacare. Through the courts, funding cuts, changes to the law, or simply not implementing parts of the law, they have done everything in their power to make sure that the ACA is as ineffective as possible. Then, as a culmination of years of campaigning on getting rid of this anathema, they finally win control of the White House along with maintaining majorities in both chambers of Congress. Their chance had arrived!
For seven years since its passage, it had been the unifying rallying cry of almost all Republican candidates that they would repeal and replace Obamacare. They were so focused on campaigning on this issue for all of those years that they somehow forgot that they actually had to write up a piece of legislation to replace the one they so adamantly wanted to repeal. In their haste, the House passed the American Health Care Act and passed the ball over to the Senate that held three major votes that ultimately led to the rejection of repealing the ACA.
The first of these attempts included the Cruz and Portman amendments which were rejected 43-57. The Portman amendment included extra funding for those who lost Medicaid coverage. The Cruz amendment would have allowed insurance companies to offer plans that didn’t provide the essential health care benefits established under the ACA as long as they offered at least one plan that did. These alternative plans could exclude protections against pre-existing conditions, implement lifetime caps, and remove annual out-of-pocket maximums.
There was a huge consensus among health care experts that Cruz’s amendment would have encouraged adverse selection which would have led to actually increasing costs. Adverse selection in health care markets is when healthy people either don’t get coverage because they don’t believe they need it or they select cheap plans that cover very little. People who are either sick or have ongoing health care needs select plans that are more expensive because they are comprehensive or are mandated to cover pre-existing conditions.
However, because fewer healthy people would be selecting the comprehensive plans because they don’t believe they need them or don’t want to pay the extra cost, the pool of individuals who would be left under these plans would generally be sicker. This has a negative feedback effect that causes the price of these plans to increase. As they become more expensive, fewer people can afford them and forego coverage that then exacerbates the effect. Then, those healthy people who have skimpy or no plan become sick and have to move to a comprehensive plan that covers pre-existing conditions and they find themselves in a position where they can’t afford those plans either. Adverse selection. So while Cruz is technically accurate when he claims he did not attempt to take away coverage for pre-existing conditions, the reality on the ground is that’s exactly what it would have effectively done for all but a small minority. Thanks Cruz, but no thanks.
The next attempt was a proposal to repeal the ACA and delay the effective date two years to provide time for a replacement bill. The Republicans had been kvetching about this legislation for the better part of a decade and when it’s time for the rubber to meet the road they are all like, “Yeah, about that. We’re gonna need a little more time to put our big boy pants on and actually govern.” WHAT IN THE WORLD DID YOU SPEND THE LAST SEVEN YEARS DOING?! I don’t care where you fall on this particular issue—this level of ineptitude should piss every single person off. At least the other attempts did something. This proposal failed by a 45-55 vote. Funny enough, it’s saying something when the Cruz amendment got fewer Yeas than this sorry excuse for a plan-not-a-plan.
Finally, in dramatic fashion and after voting yes to advance debate, McCain became the hero of the Senate and was the deciding “Nay” vote for what became known as the “Skinny Repeal”. This bill would have basically repealed the individual mandate but kept Medicaid expansion in place. The CBO projected that it would reduce the number of insured individuals by 16 million over the course of 10 years and increased premiums by 20 percent.
One of the main reasons that the GOP offered up such a poor selection of options was that they were operating under the constraint of reconciliation. When legislation is introduced in the Senate, the members of the Senate enter debate on the bill and as long as someone takes to the floor to speak on the bill, it cannot be voted on. This is what's know as a filibuster. According to Senate Rule XXII, an end to debate can be declared with a three-fifths majority vote. This is called invoking cloture.
This is where reconciliation comes in. Since the Republicans did not have the 60 votes to invoke cloture, they had to pass a bill using reconciliation. Reconciliation is a process that allows legislation to be passed that pertains specifically to revenues and spending. If the legislation introduces or alters the function of government, like creating new programs or significantly changing current ones, then it goes beyond the limits of reconciliation and would adhere to normal legislative procedures. The Senate Parliamentarian makes the determination of whether a bill adheres to the rules of reconciliation. So, naturally, this severely limited what the GOP could produce in a health care bill.
With every single attempt that was made, at least two of the three main goals we mentioned in the opening post were not met. In fact, the needle moved in the opposite direction—compared to the status quo, costs would have increased and the number of insured people decreased. This absolutely boggles my mind. How is it that we came to a point where it was more important to dismantle an opponent’s signature piece of legislation than to actually improve our health care system? As mentioned in the previous post, unfortunately it did not end there. With the passage of Trump’s tax reform bill, the effective repeal of the individual mandate was slipped in. Similar to the “skinny repeal”, the CBO projected this would increase the number of uninsured by 13 million by 2026 and increase premiums by up to 10% in individual insurance markets.
I am curious to hear from moderates and conservatives about what their thoughts are on this entire process. Did you support these repeal and replace efforts by the GOP? If so, how does that line up with the Three Goals of more affordable health care, more effective and efficient health care, and universal coverage? Was I wrong in my assumption that those are reasonable goals that most people want? Help me understand why GOP Representatives and Senators thought these plans were what their constituents put them in office to implement.
We can do better. We must do better. Let’s see how the rest of the developed world does in Part 5…