Monday, July 28, 2014

Republicans on Obamacare: Repeal - Yes! Replace - We'll Get Back to You...

By the fourth anniversary of its signing this past March, U.S. House Republicans had voted 54 times to fully repeal, defund and/or delay implementation of the Affordable Care Act, commonly known as Obamacare. The more time goes by of course, the greater the impact of a full repeal. A recent study by the Rand Corporation found that a net 9.3 million previously uninsured Americans gained coverage during Obamacare's first enrollment period.

No problem, say Republicans, our plan is to repeal and replace Obamacare. Mitt Romney ran on "repeal and replace" in 2012, but apparently spent all his energy working on a bunch to untruths and misinformation regarding what the ACA would and would not do, thus leaving him with little time to devote to the "replace" part of his plan. As John Avlon of the Daily Beast noted in June of 2012, "
Mitt Romney still needs to decide which specific policy plan he would enact. Unclaimed ideas range from medical-malpractice reform to expanding health savings accounts to allowing insurance purchases across state lines to generic-drug importation."

And that's been the hallmark of Republican claims that they will replace Obamacare: we're working on it, nothing specific yet, we'll get back to you, we promise. With Romney's candidacy in the past, leadership on "repeal and replace" has passed to the Republican-controlled US House. This past March, in what now seems to be an incredibly gullible act of journalism on the part of the Washington Post's Robert Costa, he suggested that the Republican repeal and replace scheme was a fait accompli; not much left for them to do except vote on it:

"House Republican leaders are adopting an agreed-upon conservative approach to fixing the nation’s health-care system, in part to draw an election-year contrast with President Obama’s Affordable Care Act. The plan includes an expansion of high-risk insurance pools, promotion of health savings accounts and inducements for small businesses to purchase coverage together. The tenets of the plan -  which could expand to include the ability to buy insurance across state lines, guaranteed renewability of policies and changes to medical-malpractice regulations - are ideas that various conservatives have for a long time backed as part of broader bills. But this is the first time this year that House leaders will put their full force behind a single set of principles from those bills and present it as their vision. This month, House leaders will begin to share a memo with lawmakers outlining the plan, called "A Stronger Health Care System: The GOP Plan for Freedom, Flexibility, & Peace of Mind," with suggestions on how Republicans should talk about it to their constituents."

Powerful stuff, Mr. Costa. Small problem though: everything you just said about the Republican "plan" is not true. Just two days later, Jonathan Weisman of the New York Times put a less optimistic spin on the same news:

"Senior House Republicans — struggling to find consensus for health care legislation to replace the Affordable Care Act — are planning to test ideas in April at town-hall-style meetings that could provide a path toward a long-promised alternative to President Obama’s signature legislative achievement. The "House ObamaCare Accountability Project" is still months away from producing actual legislation. With Democrats opposed, Republican leaders will have a hard time finding enough votes for any plan, and Speaker John A. Boehner of Ohio remains cool to guaranteeing a vote."

Fast forward just six weeks, and Republicans plans seem to be in trouble. From a May article by Steve Benen:

"Despite months of assurances that the Republican alternative to the Affordable Care Act is on the way, any day now, Rep. Dennis Ross (R-Fla.) recently told his constituents what many have long suspected: "For the next six months, we're going to go into an election knowing that we’re not going to do anything to address health care."

"In fact, David Drucker reports that the 35-member House Obamacare Accountability Project – honestly, that’s what it’s called – is still plugging away. "[The] working group of about 35 GOP members, has written a “draft” proposal to repeal and replace the Affordable Care Act, according to one House Republican familiar with the effort. But the group has not shared the draft with their colleagues and is engaged in an internal debate over whether their goal should be to simply introduce legislation, or also hold floor votes."

Weeks later, we don't seem to have heard much more about the House plan. Although I do note this interesting observation last month from Elise Viebeck of the Hill, "House leaders have organized a group known as HOAP — the House ObamaCare Accountability Project — to organize a messaging strategy against the law that will trickle down to constituents."

So in three months, the House leadership has gone from promising a comprehensive plan to replace health insurance for tens of millions of Americans, to offering only a "messaging strategy." Or as Speaker John Boehner said last week, "You know, the discussions about Obamacare and what the replacement bill would look like continue." You'll notice he said, "would look like" rather than "will look like," thus implying there's no reason to believe the replacement bill will ever exist in any form.

It's not surprising that Republicans have never been able to rally around an alternative health care proposal; they've never really believed that health care reform is needed. Everyone needs health insurance. Mitt Romney himself pointed out in 2010, "It doesn't make a lot of sense for us to have millions and millions of people who have no health insurance and yet who can go to the emergency room and get entirely free care for which they have no responsibility." Of course once Romney became the Presidential nominee, he changed his tune, "Well, we do provide care for people who don't have insurance, ... If someone has a heart attack, they don't sit in their apartment and -- and die. We pick them up in an ambulance, and take them to the hospital, and give them care."

The fact that Republicans don't believe that people really need health insurance apparently makes them obtuse when it comes creating viable plans to insure the unisured. The bankruptcy of conservatives on health care reform is typified by the idea that, "people should be able to buy insurance across state lines."

There's one reason why that's a terrible idea, and another why it's completely unworkable.

It's a terrible idea because buying insurance across state lines would mean the new national standard would be whichever state least regulates insurers, sets the weakest coverage minimums and makes it most difficult to sue your insurer. Or as Ezra Klein of the Washington Post put it,

"The (insurance) industry would put its money into buying the legislature of a small, conservative, economically depressed state. The deal would be simple: Let us write the regulations and we'll bring thousands of jobs and lots of tax dollars to you. Someone will take it. The result will be an uncommonly tiny legislature in an uncommonly small state that answers to an uncommonly conservative electorate that will decide what insurance will look like for the rest of the nation."


The idea is also unworkable because rates in Mississippi are based on costs for care in Mississippi, not costs in California. It surprises me that this fact is not more frequently discussed in the mainstream media (or maybe it doesn't). It took me a while for find anyone saying much about it. But I finally found a good summary of the problems associated buying health insurance across state lines in an editorial in Raleigh, North Carolina's News and Observer:

"(A)n insurance company selling a policy in Arkansas wouldn't mind if I purchased such a policy so long as I went to Arkansas to use health care. If I wanted to buy a policy developed for consumers in Arkansas, but wanted to use care in North Carolina, they likely wouldn't sell it to me because the premium is based on the health care experience of someone living in Arkansas. Similarly, car insurance rates are based on loss rates in the ZIP code in which you live, because that is where you car is most often at risk of becoming a loss.

An individual health insurance premium is based on several factors: the health of the customer and therefore the expected use of care, the benefits covered, the provider network (doctors and hospitals) that patients can use and how medicine is practiced where the patient lives. State regulations influence benefits and therefore premiums. However, the way medicine is practiced (called practice patterns) where the insured person lives has a tremendous influence on premiums, but it greatly affects the expected losses of an insurance company."

Americans have made it clear they don't want what little Republicans have to offer on this subject. A HuffPost poll in April showed only 17% of Americans want Obamacare replaced with a Republican-sponsored alternative. It's also hard for Republicans to continue to claim any credibility on the subject. Republican predictions that Obamacare would not reach enrollment goals were wrong. Conservatives predicted skyrocketing insurance and healthcare costs; instead year over year insurance cost increases will probably be less than in the past as will the cost for care.

Republican rhetoric on health care is a lot like their rhetoric on taxation, the economy, foreign policy, and, well, pretty much every other subject I can think of. Once you start to compare what Republicans say and how the world actually works, Republican policy doesn't look very good.