Well, you know what they say: If at first you don’t succeed in your attempts to strip health insurance from 24 million Americans while sticking it to the sick and old, just try again.
After enduring more than a week of humiliation for failing to bring its first Obamacare repeal bill to a vote, the White House has resumed haggling with Capitol Hill Republicans over a potential health care compromise. Administration officials have sat down with both hard-line conservatives in the House Freedom Caucus, who were largely responsible for dooming the GOP's reform effort two weeks ago, as well as the more moderate Tuesday Group, to attempt to bridge the yawning intraparty divides on the issue. While nobody has made any final commitments, all sides seem to be murmuring optimistically about the negotiations. Freedom Caucus Chairman Mark Meadows told reporters that while there was no deal yet, “There is a solid idea that was offered.” Rep. Chris Collins of the Tuesday Group hinted that Trumpcare’s lurching zombie corpse might even go up for vote by the end of the week. “It was clear the president would be very happy come Friday to have this passed,” he said. "This could move fairly quickly."
So what's in the bargain? The big idea reportedly under discussion would let states opt out from some of Obamacare’s key insurance market regulations, including the “community rating” rules that bar insurers from charging sick customers more than healthy people for coverage. Carriers would still not be allowed to reject shoppers outright based on their health status. But that restriction would become fairly meaningless, since Cigna and Aetna would be entitled to charge the chronically or severely ill sky-high premiums that priced them out of coverage wherever a friendly governor allowed it. If that sounds like a de facto death sentence for the popular pre-existing conditions protections—well, yes, that's exactly what it is.
Trumpcare II would also apparently let states drop Obamacare's essential health benefits, the regulations that require insurers to require certain services like hospitalizaiton, maternity, and mental health care. While this would be an enormous and controversial change, allowing carriers to sell cut-rate plans and forcing extra costs onto people who need particular services, like women who might give birth, it might be a bit overshadowed by the outright end of community rating in some states.
Conservatives are not being coy about what their plan would do. “The fundamental idea is that marginally sick people would pay the risk associated with their coverage,” Meadows said. To compensate, Republicans reportedly want to funnel more money toward subsidized high-risk pools that would provide insurance for the chronically sick who truly can't afford it on the private market. But high-risk pools have never worked particularly well when they've been tried; they've been notorious for high premiums and long wait lists.
It should be said that, philosophically, killing off protections for Americans with pre-existing conditions and consigning them to high-risk polls is much more in line with traditional Republican health care thinking than Paul Ryan's American Health Care Act. That unloved mongrel of a bill tried to scale back Obamacare while leaving its protections for the sick in place for two apparent reasons. First, people really like them. Second, it's not clear that the Senate's reconciliation process, which Republicans are relying on to avoid a filibuster, would allow them to eliminate regulations, as this new plan more or less does. But the White House seems to have decided that it's willing to risk parliamentary problems in the upper chamber later if it means passing legislation now in the House. And kicking the final decision-making to the states protects moderate members from places like New York from being accused of eliminating well-liked protections for their own constituents.
But this state-by-state approach to regulation is just a rhetorical fig leaf that isn't that meaningfully different than killing off rules entirely. After all, if New York or California legislators wanted to continue enforcing restrictions like community rating, they could still write them into state law no matter what Washington did. This just reverses the process.
One of Obamacare's key achievements was that it set into law the principle that people with health problems shouldn't be discriminated against when it came to insurance coverage, no matter where they lived. The new Republican plan would undo that. It's perfectly in keeping with conservative orthodoxy. It's also a bit sick.