Vicki Hopper, a constituent of Rep. Tom Price (R-Ga.) from Roswell, Ga., lost her job two years ago but has kept her insurance through the Obamacare exchange. She says the price is “high, but affordable” since the subsidy cuts her payment to $370 per month. On Wednesday, she met with staffers in the offices of Sens. David Perdue (R-Ga.) and Johnny Isakson (R-Ga.). “I told them you just can’t repeal it fully,” she told me. “There’ll be chaos.” She’s convinced Republicans won’t really go through with repeal.
In late November Perdue was indeed quoted as saying he was looking at partial repeal. However, along with Sen. John McCain (R-Ariz.), he has introduced a repeal and replace plan based on Price’s idea. Defenders of the Affordable Care Act are sure to point out that out-of-pocket costs to purchase the same ACA insurance many people now have will likely rise. The GOP plans, including Price’s, offer lower-premium but higher-deductible coverage, so the average person may wind up with higher health-care costs, although they may be offset in part by pretax health-care savings accounts. Because GOP plans would remove the ACA cost-sharing that keeps premiums lower for older Americans, the impact could be particularly severe for individuals aged 55 to 64, who happen to be among President Trump’s strongest supporters and the most reliable voters.
Moreover, the provision that government would sustain high-risk pools for a billion dollars a year may not pass the straight-face test. States that have had such systems in which all the hard-to-insure are grouped together have quickly run out of money. Absent a virtually unlimited stream of federal support, the hard-to-insure may find themselves once again uninsurable.
Isakson’s position is somewhat more nuanced. A senior adviser says that he wants to see a full repeal with a sustainable replacement in which oversight is largely returned to the states. However, he has said he supports preserving portions of the Obamacare law that made sense, including coverage for preexisting conditions and allowing young Americans to stay covered through a parent’s health insurance up to the age of 26.
Listen to House Speaker Paul Ryan (R-Wis.) and you’ll come away thinking the GOP alternative plan is ready to go. On PBS NewsHour he told Judy Woodruff that “we ran on a replacement plan, by the way.” He insisted, “So we have had a — long had a replacement plan for Obamacare. And that’s exactly what we’re focused on right now is building a replacement plan, so we repeal Obamacare and replace it with patient-centered health care, which we are convinced will give us a better system at the end of the day.” So if they have the plan, where is it?
Perdue-McCain has one idea (which may or may not match up with what Price suggests once confirmed at HHS); Sens. Susan Collins (R-Maine) and Bill Cassidy (R-La.) have another, one in which states can opt to keep Obamacare and which offers states the option of automatically enrolling their residents in a high-deductible plan that nevertheless bars insurers from setting annual and lifetime limits and excluding people with preexisting conditions. (It would keep popular provisions that allow adult kids to stay on their parents’ plan and would cover mental health and substance abuse plus would limit out-of-network fees paid through a health spending account.)
As we heard in the leaked tape from the GOP retreat, no consensus exists on what the replacement will look like or on how to proceed. The White House seemed to kill “repeal and delay.” House members are talking about trying to put some new provisions into the reconciliation/repeal process. But Sen. Mike Lee (R-Utah) wants to go back to repeal and delay. “‘If we load down the repeal discussion with what comes next, I think it’s going to make it a lot harder to get either one of them done,’ Lee said during a reporter briefing sponsored by the Heritage Foundation. ‘We need to repeal it first before deciding what comes next. I think there is a lot of agreement among Republicans in Congress with regard to the repeal bill. There is a lot less agreement on what comes next.’” So they are going to repeal without knowing what if anything comes next. This is precisely what the White House rejected. It’s what voters like Vicki Hopper would call “chaos.”
An uncomfortable political reality hangs over the entire process: If the GOP replacement proves controversial (how could it not?), Trump, ever desirous of maintaining his own appeal and with no loyalty to the GOP, could declare whatever Congress produces a “loser” or a “failure.” In that event, Republicans would have taken immense political heat — only to get stabbed in the back by the mercurial and emotion-driven president. Does this all look like we are on the verge of seeing Obamacare repealed and replaced?
UPDATE: Sen. David Perdue’s office clarifies that he has always been in favor of repealing all of Obamacare, but pragmatically he has recognized this might be done in stages or, unlike Obamacare, in multiple pieces of legislation on specific topics (e.g., high-risk pools).