Republicans' absurd excuse for a healthcare reform plan is in trouble. Again. Despite initial claims that he could muster 50 votes to pass it by the end of the week, on Tuesday Senate Majority Leader Mitch McConnell shelved the bill until after the upcoming July 4 recess, seeking yet more time to get his caucus together. This endless saga of infighting and false starts, not to mention the plan's unpopularity, may explain why on Friday morning President Donald Trump rage-tweeted that Republicans should just repeal Barack Obama's Affordable Care Act, then come up with a new approach.
That strategy, known as "repeal and delay" has already been floated at least three times in this Congress alone. In fact, before Republicans settled on their current healthcare strategy, there were already several diverse plans on the table. As the Senate bill languishes, it's worth looking back at those alternatives to understand the debates we could have been having for the past few months and why we wound up (and are probably stuck) with the steaming shit pile we have now.
Hundreds of bills dealing with healthcare have been submitted for consideration in the current Congress. Many of them propose simple tweaks, like expanding the use of healthcare savings accounts (HSAs), a longstanding Republican idea intended to help people sock money away, ideally mostly tax-free, to pay for future healthcare costs. But there hasn't been a lot of appetite for marginal changes. When we talk about alternative plans, we're talking about those that would completely overturn the ACA framework rather than jigger with it a bit.
Republicans launched their healthcare campaign on January 3, the first day of Congress, when Wyoming Senator Mike Enzi initiated the reconciliation process currently being used to pass this major legislation with a simple majority vote. That motion passed on January 12, but we didn't get the first inklings of an official bill from House Republican leadership until mid-February. The first draft of that chamber's ultimate product, the American Health Care Act, came out March 6.
But there were options circulating before then. On January 23, Republican senators Bill Cassidy of Louisiana and Susan Collins of Maine introduced the Patient Freedom Act of 2017. Based on a 2015 bill, this moderate proposal called for states to individually choose whether to keep the ACA, scrap it and transfer their uninsured to high-deductible plans bolstered by federally-augmented HSAs, or opt out of any type of federal support. The plan sought to maintain the status quo where it worked, offer a conservative-aligned universal coverage scheme elsewhere, and leave ultra-conservatives the option of totally abandoning state-supported healthcare.
Two days later, relentlessly anti-government Kentucky Senator Rand Paul proposed his Obamacare Replacement Act, later mirrored in the House by Freedom Caucus heavy Mark Sanford of South Carolina. This proposal would have mostly ripped up the ACA, offering just minimal protections for pre-existing conditions so long as people maintained continuous coverage. It would have offered annual tax credits for deposits made into HSAs, which could be used for more procedures and to pay premiums, and allowed tax deductions for private insurance. It would have also expanded the bodies that could offer insurance and legalized sales across state lines. Yet it said oddly little about the ACA's taxes or Medicaid expansion, major points of contention for conservative ideologues duking it out over the current bill.
In February, Republican Representative David Roe of Tennessee brought his American Health Care Reform Act of 2017 to the House, essentially acting on behalf of the Republican Study Committee, the slightly less conservative alternative to the Freedom Caucus. Similar to proposals from 2013 and 2015, it called for a repeal of the ACA even more comprehensive than that in Paul's bill, but mirrored many of his other post-ACA tweaks and systems.
In March we got a couple straggler proposals: House Republican Pete Sessions of Texas offered up the comically named World's Greatest Healthcare Plan of 2017, a rehash of a 2016 proposal that remixed many of the conservative talking points of the previous two plans. House Republican Darrell Issa of California's Access to Insurance for All Act axed the ACA and opened the insurance options available to federal employees across state lines to all Americans.
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Only the Cassidy-Collins and Paul plans garnered real, sustained media scrutiny, and that was mostly because they were the first salvos of the Congressional season. Even these bills weren't dissected deeply, though. Their legislative language was vague and incomplete, and whatever their virtues they never had the backing of leadership.
As healthcare policy wonk Len Nichols explained to me, healthcare is so complicated that "nothing registers until it's repeated by leadership in their media talking points, multiple times."
All of these bills were serious, said Nichols, in the sense that they advanced ideas their authors felt deeply about. Simultaneously though, argued Michael Cannon, a health policy expert at the libertarian Cato Institute, they weren't serious proposals because they didn't seek to become the basis for the tightly controlled leadership process that gave us the bills that actually could pass. These test balloons were clearly and outwardly attempts to kick a slow process into gear and make sure Republican leadership knew where various factions stood, which ideas they valued.
"They are all signaling exercises," said Cannon. "Of course, those can morph into 'serious proposals'" if leadership decides to adopt and flesh out those broad ideas.
A moderate proposal like the Cassidy-Collins bill, said Nichols, kept too much of the ACA to have any place in leadership-led negotiations, currently seek to move towards the center from the right. A bill like Paul's probably played some role in shaping current legislation. But more important than any policy idea was the fact that using reconciliation limits what can go in a bill. Selling insurance across state lines, for instance, a policy Trump himself supports, is out, as are small but key elements in most of the alternative Republican healthcare plans floated this year.
Republicans could pass any bill they wanted if they could garner 60 votes, rather than the 50 needed for reconciliation bills. But McConnell and company evidently figure that no Democrat would sign on to a bill gutting the signature legislative accomplishment of the Obama era, as all of the existing Republican proposals do to some extent, even the Cassidy-Collins bill.
"So we got what we got," said Nichols. "And McConnell is trying hard to square a circle."
If McConnell totally fumbles the Senate healthcare bill and no other Republican alternatives emerge, one other plan floating around the senate might gain steam: House Democrat John Conyers of Michigan's Expanded and Improved Medicare for All Act, which would cover all uninsured Americans by building out Medicare beyond the ACA expansion. Conyers has advanced some version of this bill every year since 2003. But Bernie Sanders, who plans to submit an equivalent for consideration in the Senate this year, gave the idea a boost with his presidential campaign. It doesn't have official leadership backing, but the proposal could rise to prominence as part of the Democratic platform in 2018 or 2020.
But for now at least, no alternative healthcare reform plan has any space to flourish, not with the constraints Republican leadership has placed on itself.The best we can hope is that McConnell continues to fumble, and Republicans for the sake of national wellbeing and of resolving their helathcare mess wind up negotiating a bipartisan bill that stabilizes the ACA marketplaces.
"I fear though," said Nichols, that "if McConnell fails, Trump will sabotage the marketplaces and Republicans will be even more scorched-earth on tax cuts, immigration," and other policies moving forward.
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