Editor’s Note: This is the second of a two-part series on the state of U.S. healthcare and its future.
Using the process of budget reconciliation, Senate Republicans have ensured that they can pass a bill to repeal the Affordable Care Act (ACA) with just 51 votes, avoiding filibuster. This loophole – traditionally utilized to pass budgets and address the deficit – is a huge step for Congressional Republicans in their quest to repeal the ACA, commonly known as Obamacare.
Last week, I looked at the failures of the ACA and how they can be addressed. At this point, it has become clear that the GOP has no intention of fixing the ACA, only of repealing it. However, the Republicans are already running into roadblocks. The GOP holds 52 seats in the Senate, plus the potential for a tie-breaking vote from Vice President Mike Pence. That means they can lose, at maximum, two votes from their own side before an Obamacare repeal becomes impossible.
Already, the GOP is facing pushback from some of its own members, many of whom oppose repealing the law before a replacement plan is ready to be enacted. Without an alternative in place, repealing the ACA could cost 18 million Americans their health insurance in the first year alone, according to the Congressional Budget Office. This was the reasoning that led Kentucky Senator Rand Paul to defect from his party on the budget reconciliation vote. Senator Paul could continue to be a thorn in the side of the Republicans throughout this process. Similar concerns have been raised by Senators Tom Cotton (R-Ark.), Bob Corker (R-Tenn.) and Lamar Alexander (R-Tenn.). Any repeal plan is also likely to include provisions to defund Planned Parenthood, bringing the resolution into conflict with more moderate Republican Senators like Lisa Murkowski of Alaska and Susan Collins of Maine. While party fealty is a strong force, any two of these senators could cripple a GOP repeal plan.
If the Senate Republicans want to assure the passage of an ACA repeal package, they may have to finally offer an alternative. So what might this Republican healthcare plan look like? President Trump complicated the answer to that question earlier last week when he announced that he is crafting his own ACA alternative, one that will provide “insurance for everybody,” while also forcing pharmaceutical companies to negotiate directly with the government on prices for Medicaid and Medicare. These descriptions are consistent with the single-payer and universal healthcare systems offered by many European countries, the types of plans that Republicans have denounced as being socialist and inefficient for decades.
While Trump has offered few other details – “much lower deductibles” – and his policy proposals are infamously transient, these comments suggest that Trump has little interest in the details or the principles of proposals put forth by Congressional Republicans.
If Trump holds true to his promises, his plan will conflict with the proposal put forth by his own nominee to be Secretary of Health and Human Services (HHS), Rep. Tom Price (GA). As head of HHS, Price will oversee the implementation of any ACA replacement. While in Congress, he authored the Empowering Patients First Act, one of the most thorough and specific conservative healthcare plans in opposition to the ACA. Price’s plan highlights an ideological difference on healthcare policy between Republicans and Democrats. The ACA was crafted to be a safety net for the poorest and sickest. Its ban on the practice of denying coverage to patients with pre-existing conditions and its inclusion of essential benefits aid the sick. Its cost-sharing measures make it affordable for the elderly, and its expansion of Medicaid is crucial for the poor to be able to afford health insurance.
Price’s plan is far more beneficial for young, rich and healthy Americans, who won’t be asked to pay more to offset the costs of disadvantaged Americans as they were under the ACA. It also ends the Medicaid expansion, which has helped 16 million Americans secure insurance since 2013, while offering no alternative. Price’s plan is consistent with the conservative view of healthcare; it is not a safety net or a redistributive program, but insurance against disaster, and personal coverage based on your personal risk of illness.
The first problem with Price’s plan is that it disadvantages the elderly, a core conservative constituency. Even more problematic, it offers less aid to the poor than does House Speaker Paul Ryan’s ACA replacement plan, and conflicts with Trump’s proposal. Discussing his plan, Trump announced, “We’re going to have insurance for everybody … There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” I doubt he knew that those circles included the Speaker of the House and his own nominee for Secretary of HHS.
Healthcare policy is incredibly complex and contentious. Democrats learned the same lesson in 2009 when they debated Obamacare, which only passed in 2010 when they controlled 57 seats in the Senate. This coalition was capable of withstanding a filibuster and inter-party defections. The margin of error for Republicans in Congress right now is slimmer. Before the election, the GOP was in shambles, divided by severe ideological fissures. Those cracks are materializing again, even as Republicans attempt to achieve their signature policy proposal. Until the GOP can determine the ideological foundation for their healthcare proposal – an equalizer or a prevention against worst case scenarios, universal or individual – the law they voted more than 60 times to repeal will continue to operate, a lasting symbol of President Obama’s legacy.