Although it will undoubtedly undergo further revisions, we now have a pretty clear idea of what the House Republican health plan entails. At the same time, House and Senate leadership's political strategy has also come into focus.
With new information about both the policy and the politics, we can now answer the questions I posed last week: How will the Republican leadership plans solve the interlocking problems of getting their budget numbers to work and securing a majority in both houses of Congress without running into a firestorm of public opposition.
Let's take these questions in order.
Wealthy are winners, low- and moderate- income and older adults are losers
There is a two-part solution to the question of how to fill the budget hole created by the Republican commitment to give big tax breaks to corporations and high-income households. First, "replace" as little of the ACA as possible to keep spending down. So, although refundable tax credits are part of the Republican plan, the tax credits are much smaller than the ones in the ACA. As a result, individuals would on average pay an additional $2,400 and family costs would increase by over $4,000.
Two groups are particularly disadvantaged by the tax credit structure, which adjusts for age but not for income. The first is lower-income people of all ages – many will find that either they cannot afford coverage at all, or that a plan with affordable premiums comes with such high cost-sharing that it is not worth it. Since there would no longer be any penalty for being uninsured, many healthy lower-income individuals would simply go without coverage.
The second big group that gets hurt is older adults. Under the House plan, tax credits for the oldest enrollees would be twice as high as for the youngest, but premiums could be five times higher or even more at the discretion of states. That would again force many people to drop coverage. So, smaller credits and fewer enrollees means less spending to offset less revenue.
Shifting costs onto states, providers and Medicaid beneficiaries
The other part of the solution is to take a giant bite out of Medicaid. First, the Republican plan phases out the ACA's enhanced match for the Medicaid expansion population. While states would still be allowed to cover this group, it would cost them much more to do so. Secondly and even worse, there would be a huge reduction in federal support for the core Medicaid program that covers low-income children and parents, people with disabilities and seniors.
The version of the House bill that leaked last week capped federal matching payments for Medicaid beneficiaries but proposed to increase the cap at the rate of medical inflation plus 1 percentage point. While this could still cause a lot of problems for specific states and beneficiaries, this is actually higher than the average growth rate per Medicaid beneficiary (hence not generating a lot of savings). The new proposal reduces the growth rate of the cap to Medical CPI, but this is unlikely to be the final word. Of course, there is no CBO score, so what happens if the numbers still don't balance? Simply go back and cut Medicaid some more.
Damn the torpedoes, full speed ahead
So much for problem number one. What about problems two and three: public opposition and not enough votes in the Senate or the House (or both)? This is where secrecy and speed come in. Speaker Ryan and Leader McConnell are trying to jam legislation through their respective chambers before either the members, the voters or other stakeholders, including providers and governors, can figure out what is in it. That's why there was so much effort to keep the text secret until the last minute, why there will be no hearings, and why the committees are not bothering to wait for analysis from CBO, the CMS actuary or outside experts. The extensive damage the bill will cause will become clearer and clearer the more time the bill hangs out there, as will the disconnect between Trump's often repeated promises of affordable coverage for all and the reality of millions losing their coverage and rising out-of-pocket costs.
Will it work?
While we should not underestimate the pressure that party leaders can put on the rank and file to fall in line, the outcome of this debate is by no means settled. On the far-right, members are complaining that the leadership proposal does not repeal enough of the ACA and outside groups are mobilizing against the plan. Many employers also oppose the plan because in addition to the benefit cuts, it caps the income tax exclusion for employer-provided health benefits. And the deep cuts to Medicaid may be too much for governors of either party to swallow while adding new constituencies among both consumers and providers to the ranks of the opposition.
...Not if we can help it
Grassroots opposition has already had a dramatic impact on both the timing and the content of the health care debate this year. Additional pressure is needed now to slow down the renewed rush to dismantle health coverage for millions of people and force Congress to go back home and face the voters again in April before they take a final vote.