But before I get to that, let’s be crystal clear about this. The problem with the House Republican health-care replacement is not merely that it takes us back to the days when insurers could charge a lot more to people with preexisting conditions (which I’ll refer to as “pre-X”). It’s not only that it will bring back coverage limits and “medical underwriting,” allowing insurers to again raise premiums for people with cancer, asthma, heart disease, and even that common ailment afflicting half of our population: being female.
The problem with the House replacement bill is the same as it ever was, only worse. Tens of millions of people will lose health coverage, premium costs will rise for older and moderate-income persons seeking coverage in the individual market, and Medicaid will cease to cover millions of low-income people. While we haven’t, and won’t, I fear, see a new, official “score” of the latest iteration of the bill, my strong view is that it will more than unwind the benefits of the Affordable Care Act and, in the process, deliver a huge tax break to the richest households.
When the first repeal plan failed, I wrote that the politics for House R’s were like an impossible Sudoku puzzle: If you give the hard right what it wants, you lose the moderates you need. But leadership decided to go with the hardcore caucus and introduced an amendment to their already draconian bill, one that would allow states to waive the ACA’s prohibition on charging people more based on pre-X, along with a bunch of other coverage standards.
This may sound benign, but at least some moderates recognized that, as my CBPP colleague Aviva Aron-Dine put it: “The amendment would end nationwide protections for people with pre-existing conditions and restore the pre-ACA status quo. Before the ACA, states always had the option to protect people with pre-existing conditions, but very few did: 43 states plus Washington, D.C. let insurers charge people more based on their medical history. Even in the other seven states, benefit standards were generally much weaker than they are today. Plans could exclude coverage for maternity care, mental health treatment, or other key services.”
Let’s tie this change to the basic architecture of health-care reform. Fundamental to this architecture is risk-pooling, wherein healthier people subsidize sicker ones. But that’s not how this plan would work, or, more likely, not work.
Moderate Republicans, to their credit, objected to ending the coverage of pre-X and, at least at first, didn’t appear to buy the solution to this problem on offer from their fellow R’s: high-risk pools. These are what they sound like — you separate out the sickest people and pool them together. Obviously, since they’re the most expensive to cover, the people swimming in these pools will need to be either very rich or very subsidized.
History is replete with examples of high-risk pools that have foundered on this logic. It’s not that they can’t work. It’s that they don’t work, because they’re always underfunded. And this is where the latest wrinkle comes in.
On Wednesday, Republicans added a sweetener amendment to the bill to assuage the moderates’ concerns that underfunded high-risk pools would leave millions of vulnerable people without coverage (or, same thing, with unaffordable coverage). After all, the Congressional Budget Office projected that the uninsured rates for people in their pre-X years would double (84 percent of 55- to 64-year-olds have pre-X). The amendment is supposed to offset the impact of the state waivers with $8 billion over five years.
It won’t come anywhere close to doing so. To call this “lipstick on a pig” would be an insult to stylish porkers. First, it restores less than 1 percent of the cuts from the House bill. Second, even assuming that pre-Xers could afford annual premiums of $10,000, the risk pools would still be underfunded by more than $200 billion.
Finally, as Avon-Dine points out, this funding would be available only to states seeking waivers, creating “even stronger incentives than the current bill for states to drop these protections. That could make the bill even worse than before for people with serious health needs.”
I can’t believe the moderates withholding their support don’t know these facts. They surely realize this amendment provides them no real cover. Thus, those who flip their positions under this flimsy cover should be held to account.
But the larger point is that this is all really just a jumble of complete nonsense. House Republicans have a bill that breaks the ACA, and now they’re playacting at fixing what they broke. But they’ve never been able to escape the logic of health-care coverage. Either a) healthier people subsidize the less healthy through true risk pooling, b) you get the money for that subsidy somewhere else, or c) you pretend you’ve got it covered through phony amendments and shift the costs of coverage onto the patients themselves, either through sky-high premiums or, more likely, the loss of coverage to those who need it the most.
In case I haven’t been clear enough, the House R’s choose “c.”