Sens. Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska) stood tall against partisan pressure in voting to stop a disastrous health-care bill. Now, in the context of the tax bill, they are prepared to vote for a bill that would repeal the individual mandate, causing grave economic disruption to the individual market and leave 13 million fewer insured.

The excuse that they have gotten assurance that the president will back the legislation to preserve cost-sharing reduction subsidies to insurers doesn’t make sense. Timothy Jost at Health Affairs explains:

The two bills are the Alexander-Murray bipartisan health reform bill, which would provide funding to reimburse insurers for reducing cost sharing for low-income enrollees for 2018 and 2019, and another bill that Senator Collins is co-sponsoring with Senator Bill Nelson (D-FL). The Collins-Nelson bill would provide $2.25 million in funding for 2018 and for 2019 for states that obtained 1332 innovation waivers to institute reinsurance programs.
The assumption underlying this trade-off is presumably that adoption of Alexander-Murray and Collins-Nelson would offset the damage done to the individual market by repeal of the individual mandate. However, on November 29, 2017, the Congressional Budget Office released a letter to the Senate Health, Education, Labor, and Pension Committee ranking member, Senator Patty Murray (D-WA), confirming that adoption of the Alexander Murray bill would not begin to offset the dramatic increase in the number of uninsured that would be caused by the individual mandate repeal.
In its November 8, 2017 report on individual mandate repeal, the CBO estimated that repeal would cause 4 million individuals to lose coverage by 2018 and 13 million by 2025. In its October 25, 2017 analysis of the Alexander-Murray bill, the CBO estimated that it “would not substantially change the number of people with health insurance coverage, on net, compared with [the CBO’s] baseline projection.” . . . The CBO’s November 29 projection, therefore, that Alexander-Murray will not begin to offset the coverage losses of the individual mandate repeal is consistent with its earlier projection that CSR funding has little effect on coverage, one way or the other.

As for the Collins-Nelson bill, a Rand Corp. study calculated that it would increase coverage by 1.2 million (not enough to offset the 13 million who will lose coverage) and would reduce premiums by 3.9 percent, not enough to offset “the 10 percent premium increases that the CBO predicts would be attributable to the individual mandate repeal.”

As Topher Spiro of the Center for American Progress tweeted: “Let’s be clear: Alexander-Murray is no substitute for the individual mandate. At the most basic, obvious level, there is no alternative to the individual mandate in Alexander-Murray. Pretty simple stuff.” He continued: The Alexander Murray bill “will lower premiums for silver exchange plans only. Thus, even with [Alexander-Murray] repeal of the individual mandate will still increase premiums for bronze, gold, and platinum plans both on and off exchanges; silver plans off exchanges; and ALL plans beyond 2019.”

As a political matter, Collins and Murkowski would be foolish to give way, since the White House has already said the individual mandate repeal could come out of the bill. (It was not in the House bill, of course.) Collins and Murkowski are being less protective of health-care coverage in this instance than Office of Budget and Management Director Mick Mulvaney.

Another argument — that the repeal of the individual mandate wouldn’t be the same as throwing people who already have insurance off insurance — is entirely specious. The individual mandate unwinds the exchanges, allowing young and healthy people to stay out of the risk pools, making coverage more expensive and even unaffordable for those who remain. Surely, Collins and Murkowski know this to be the case from the Obamacare repeal debate. Simply put, as the Center on Budget and Policy Priorities found, “Pairing mandate repeal with the Collins-Nelson bill, or a similar approach, … would not change the fact that repealing the mandate would drive up uninsured rates. That would weaken access to care, health, and financial security for millions of people. It would also substantially raise uncompensated care costs, which would ultimately be borne by providers, other health-care consumers and taxpayers.”

None of this addresses the damage that the bill may do to Medicaid and Medicare. Because of the deficits it creates (an issue that has thrown the entire legislative process into confusion), there may be a $25 billion sequester in Medicaid and Medicare funding in 2018 alone under the so-called pay-as-you-go (PAYGO) rules. Collins has said she’d oppose that, but her colleagues do not show the same concern.

It should behoove Collins and Murkowski to reconsider their position as the rest of the bill is now being reworked. Patient advocates, hospitals and doctors groups remain mystified by their about-face. Democrats are incredulous that a provision that is NOT a must-have for Republicans leadership or the White House would get the support of these two lawmakers. If they go along with this gambit, the goodwill they gained in the health-care debate would evaporate. Fortunately, as Republicans are compelled to redesign their bill, Collins and Murkowski have the perfect opportunity to reclaim their role as guardians of health-care coverage.