Wednesday, June 28, 2017

ACA vs. AHCA vs. BCRA

If it wasn't so serious, we would mock it as an overhyped pro wrestling card for a local event: Who's gonna get the smackdown? We know who: those relying on Medicaid for health care coverage.

Progressives, don't get excited and don't get discouraged, Conservatives. We are watching a negotiation and chances are good something will pass Congress for the president's signature.

Analysis of what has happened to date mixed with predictions and a read on the key players:

1. Donald Trump will sign whatever is put before him. He is not interested in the details as long as he can tweet that Obamacare is repealed and he has kept a campaign promise. Any Republican legislation that overturns the additional taxes of the ACA and ends the individual mandate will be seen as the repeal promised for six and a half years.

2. Depending on the final version, the overhaul of federal law governing health care coverage will cause 22 to 26 million people to be uninsured, according to the Congressional Budget Office.

3. The failure of the Senate to have enough votes to pass a 'motion to proceed' to debate mirrors the difficult process the House had in passing legislation. As in the House, moderate Republicans and hard-line Republicans have conflicting goals: preserve expanded Medicaid coverage for the former and curtail Medicaid costs for the latter. We cannot have both.

4. When it comes to Medicaid, the hardliners are pushing for more than repeal of expanded eligibility. They seek to enact, for the first time, limits on how much the federal government will reimburse states for Medicaid expenditures. They seek to provide something akin to a block grant and to disclaim responsibility for the consequences--they want to say the states decided how to cut back on coverage.

5. Key senators who were in the group that drafted the Senate legislation have refused the current version; this is why the Majority Leader had to delay the procedural vote. The legislation has to be revised.

Thus, it is far from certain that the bill is doomed. It is far more likely that the Senate will go the House route by changing the draft to accommodate the hardliners and attempt to force the moderates to go along.

The strategy is far from certainty of success. The Senate majority is far slimmer than the House. But to date, only two Senators have said they will not support a bill that drastically curtails Medicaid coverage.

6. Expect hard bargaining to go on throughout the holiday weekend and the Senate to proceed to debate and a vote the second week of July.

7. Something will pass.

8. And the 2018 campaign will commence. Democrats are in retreat from their losses, but they take heart in this: in our era, every attempt to pass great change in American's access to health care has resulted in a change of power in Congress.

9. The end of the individual mandate is the most problematic part of the Republican effort to overhaul the nation's health care law. Neither the 30% extra charge of the House nor the 6 month wait period of the Senate (they almost didn't do anything to penalize those who will wait until they are sick to sign up for coverage) are great enough to disincentivize the healthy from being uninsured until they are sick and dropping insurance if they become well.

It will be the end of health care insurance, period. No private enterprise will be able to sustain a profitable business model under these circumstances.

10. So in the end, the Republicans may be achieving the goal of progressives (unintentionally) of course. For when the health care insurance market dies, there will be no alternative but for the federal government to provide single-payer coverage.