House Freedom Caucus member Rep. Justin Amash (R-Mich.) voted for the health-care bill that barely — and hastily — passed the House on Thursday. But after a few days of reflection, Amash is conflicted about his vote. And he may not be the only one: House Republicans from all ideological perspectives have questioned whether the bill does what they want it to, right as the Senate prepares to seriously rework it. To get a better sense of why some House Republicans have voter's remorse — and what it could mean for any actual changes to Obamacare — I've annotated a long Facebook post that Amash put up over the weekend. My thoughts are in italics; all other text is Amash's.
AMASH: This is not the bill we promised the American people. For the past seven years, Republicans have run for Congress on a commitment to repeal Obamacare. But it is increasingly clear that a bill to repeal Obamacare will not come to the floor in this Congress or in the foreseeable future.
THE FIX: This is a pretty remarkable sentence. A conservative leader who has made his political career in Congress on opposing Obamacare is acknowledging that Republicans, who control both chambers of Congress and the White House, probably won’t do it. Why? Let’s read on.
When Republican leaders first unveiled the American Health Care Act, a Democratic friend and colleague joked to me that the bill wasn’t a new health-care proposal; it was plagiarism. He was right.
i.e.: This is Obamacare 2.0
The AHCA repeals fewer than 10 percent of the provisions in the Affordable Care Act. It is an amendment to the ACA that deliberately maintains Obamacare’s framework. It reformulates but keeps tax credits to subsidize premiums. Instead of an individual mandate to purchase insurance, it mandates a premium surcharge of 30 percent for one year following a lapse of coverage. And the bill continues to preserve coverage for dependents up to age 26 and people with pre-existing conditions.
On this, Amash is right. The big pieces of Obamacare are still largely intact under the House bill. People can still buy insurance on federal and state health exchanges, and lower-income people can still receive subsidies to help them out.
I want to emphasize that last point. The bill does not change the ACA’s federal requirements on guaranteed issue (prohibition on policy denial), essential health benefits (minimum coverage), or community rating (prohibition on pricing based on health status). In short, Obamacare’s pre-existing conditions provisions are retained.
Amash is splitting hairs here. Technically, this bill doesn't change federal requirements that health insurance companies accept someone with preexisting conditions. But it allows states to change those requirements. If states do apply for waivers to preexisting conditions rules (and already Wisconsin Gov. Scott Walker (R) has said he'd consider it), nonpartisan health-care experts think the end result is the same: On the whole, health care becomes more expensive for people with preexisting conditions who do not maintain continuous coverage — but potentially cheaper for people without.
The latest version of the AHCA does allow any state to seek a waiver from certain insurance mandates, but such waivers are limited in scope. Guaranteed issue cannot be waived. Nobody can be treated differently based on gender. And any person who has continuous coverage — no lapse for more than 62 days — cannot be charged more regardless of health status.
Consider what this means: Even in a state that waives as much as possible, a person with a pre-existing condition cannot be prevented from purchasing insurance at the same rate as a healthy person. The only requirement is that the person with the pre-existing condition get coverage — any insurer, any plan — within 62 days of losing any prior coverage.
Yeah, but: If you lose your insurance and try to get back on and you have a preexisting condition (this bill doesn't specifically define what that means), you will likely get charged an arm and a leg for health insurance for the next year, which this bill would allow. And Gary Claxton, a health insurance analyst with the nonpartisan Kaiser Family Foundation, tells me insurance companies WILL take advantage of this to charge higher rates. Why wouldn't they, when sick people cost them more to cover?
If a person chooses not to get coverage within 62 days, then that person can be charged more (or less) based on health status for up to one year, but only (1) in lieu of the 30 percent penalty (see above), (2) if the person lives in a state that has established a program to assist individuals with pre-existing conditions, and (3) if that state has sought and obtained the relevant waiver. Here in Michigan, our Republican governor has already stated he won’t seek such a waiver, according to reports.
This is a weird way to justify voting for a piece of legislation. Essentially, Amash is saying: Yeah, I don’t like the fact it lets governors essentially raise the price of insurance for people with preexisting conditions, but I’m pretty sure my governor won’t do it, so it’s okay.
So why are both parties exaggerating the effects of this bill? For President Trump and congressional Republicans, the reason is obvious: They have long vowed to repeal (and replace) Obamacare, and their base expects them to get it done. For congressional Democrats, it’s an opportunity to scare and energize their base in anticipation of 2018. Neither side wants to present the AHCA for what it is — a more limited proposal to rework and reframe parts of the ACA, for better or for worse.
I think what Amash is trying to say here: Republicans want to frame this legislation as the beginning of the end of Obamacare. He doesn't think that's quite right. Democrats want to frame this legislation as the beginning of the end of House Republicans' majority, and Amash doesn't think that's quite right, either. Amash sees this legislation as a tweaking of Obamacare, "for better or for worse."
In March, when this bill was originally scheduled to come to the floor, it was certainly “for worse.” The previous version provided few clear advantages over the ACA, yet it haphazardly added provisions to modify essential health benefits without modifying community rating — placing the sickest and most vulnerable at greater risk.
Here's what Amash said about the first version of the legislation:
Obamacare 2.0: Bad policy meet bad Republican politics meet bad Democratic politics. The elusive lose-lose-lose.
— Justin Amash (@justinamash) March 20, 2017
Over the last month, several small but important changes were made to the bill. The current version abandons that fatally flawed approach to essential health benefits (though the new approach includes new flaws), incorporates an invisible risk sharing program, and permits limited state waivers. These changes may slightly bring down (or at least slow down the increase in) premiums for people who have seen rates go up. Even so, the AHCA becomes only marginally better than the ACA.
Many have questioned the process that led up to the vote on May 4. I have publicly expressed my disgust with it.
It was pretty rushed. Republicans amended the original bill significantly, had no public hearings, did not wait for the nonpartisan Congressional Budget Office to analyze how this would affect people's health insurance or how much it would cost. It felt like, I wrote last week, this health-care bill is more about sending a political message to Republicans' constituents than any real attempt to change health-care policy.
The House again operated in top-down fashion rather than as a deliberative body that respects the diversity of its membership. But it’s important to acknowledge that the bulk of this bill (123 pages) was released on March 6. Only about 15 pages were added after late March. Members of Congress were given sufficient time to read and understand the entire bill.
Apparently, some GOP lawmakers didn't read it anyway.
— Colin Campbell (@colincampbell) May 5, 2017
While an earlier version of the AHCA included a CBO score, the types of changes made to the AHCA in more recent stages render an updated score highly speculative and practically meaningless. For that score to be useful, the Congressional Budget Office would have to effectively predict which states will seek waivers, which waivers they will seek, and when they will seek them. This complex analysis of the political processes and choices of every state is beyond anyone’s capability. I weighed the lack of an updated score accordingly.
UPDATE: I originally said: "I'm not sure what this means. Did he try to calculate his own analysis? Was he more or less skeptical of the bill because there was no CBO score?" But it looks like Amash explains what he means in the paragraph below: An updated score wouldn't be useful, because how can the CBO really know how many states would apply to opt out of key parts of Obamacare.
When deciding whether to support a bill, I ask myself whether the bill improves upon existing law, not whether I would advocate for the policy or program if I were starting with a blank slate. In other words, the proper analysis is not whether it makes the law good but rather whether it makes the law better. In this case, I felt comfortable advancing the bill to the Senate as a marginal improvement to the ACA. The House has voted more than 30 times to amend (not just repeal) Obamacare since I’ve been in Congress, and I have supported much of that legislation, too, on the principle of incrementalism. If it advances liberty even a little (on net), then I’m a yes.
This is the key line from Amash's explanation. (BTW: He prides himself on explaining every vote he takes to his constituents.)
Amash is saying here: Something is better than nothing.
Nonetheless, the ACA will continue to drive up the cost of health insurance — while bolstering the largest insurance companies — and the modifications contained in the AHCA cannot save it. Many of the AHCA’s provisions are poorly conceived or improperly implemented. At best, it will make Obamacare less bad.
The Framers of the Constitution understood that federalism — the division of powers between the national and state governments — would maximize the happiness of Americans. As long as Washington dictates health insurance policy to the entire country, there will be massive tension and displeasure with the system. I’ve always said, and I will continue to say, we need to start over: Fully repeal Obamacare, let the people of each state choose their own approach, and work together in a nonpartisan manner.
Except, even lawmakers like Amash think that won't get done.