The GOP Healthcare Minefield: MAGAcare Comes to Life

Late last week, Politico was able to obtain an early draft of the proposed ACA repeal and replacement legislation currently weaving its way through the corridors of Congress.  Republicans are trying to piece together a platform that removes the most hated elements of Obamacare, while still maintaining a Federal structure to provide access to health care insurance.

The draft proposal has a myriad of problems and hurdles to overcome, not least of which is it lacks a title. I for one have proposed the “Make America Great Again Health Care Reform Act” (MAGAcare).  But they, I’m sure they will come up with a running title worse than that.

For me, the most significant proposal for most Americans is replacing income-based tax credits with age-adjusted tax credits. This seems esoteric on its surface, but would have a tremendous impact on how much access lower-income Americans (most of whom are young, after all) will have. It would dramatically shift the financial burden on to the poor and youth of America, while older (and generally wealthier) Americans would come out ahead.

The bill also likely would go a long way to further destabilize the already unhealthy Obamacare insurance exchanges.  By 2020, the bill would end cost-sharing reductions that help low-income people cover the out-of-pocket payments that most exchange plans impose, including deductibles. Additionally, they spend no money in 2018 and 2019 to fund those cost-sharing reductions in the interim.  Finally, and maybe most profoundly, the bill ends the individual mandate, one of Trump’s core promises. But the replacement, the continuous coverage provision that would require people to keep insurance constantly in order to guarantee access to insurance, likely would not be strong enough to force people into the marketplace.  As such, many young and poor likely will opt out all together, further risking the death spiral that many have feared from the beginning.

The most daring proposal at this point is the repeal of Medicaid expansion. The program has added more citizens to the insured rolls than any other part of the ACA, and as such, is very expensive but also fairly popular.  Local officials, predominantly Republican Governors, are frightened of any proposal repealing a program that would leave millions of low-income people without sufficient health care access.

On Friday, Governor John Kasich of Ohio, arguably the leading Republican proponent for the ACA, went to the White House to make his case for Medicaid expansion. If reports are to be believed, he had a receptive audience, not only from Presidential Son-in-Law Jared Kushner, but from the President himself:

A meeting Friday afternoon between President Trump and Ohio Gov. John Kasich, his former rival in the GOP primaries, had no set agenda. But Kasich came armed with one anyway: his hope to blunt drastic changes to the nation’s health-care system envisioned by some conservatives in Washington.

Over the next 45 minutes, according to Kasich and others briefed on the session, the Governor made his pitch while the president eagerly called in several top aides and then got Health and Human Services Secretary Tom Price on the phone. At one point, senior adviser Jared Kushner reminded his father-in-law that House Republicans are sketching out a different approach to providing access to coverage. “Well, I like this better,” Trump replied, according to a Kasich adviser.

For hard-core conservatives, the fact that Trump prefers any health care proposal of Kasich’s over the mainstream Republican plans is frightening, to say the least. The messaging from the White House on this program has been muddled so far.  Asked by George Stephanopoulos, host of ABC’s “This Week,” whether Trump “won’t touch Social Security, Medicare or Medicaid,”  Deputy Press Secretary Sarah Huckabee Sanders responded, “Look, the president is committed to doing that. ...And I don’t see any reason to start thinking differently.” It is unclear how  you avoid touching Medicaid while still keeping the promise of repealing the Affordable Care Act- the Medicaid expansion was a core part of the law.

Trump is likely to garner more opposition to current Republican congressional plans on Monday, when he meets at the White House with some of the nation’s largest health insurers. including top executives from Blue Cross and Blue Shield, Cigna and Humana. This meeting gives those insurers every opportunity to lobby the President on maintaining federal financial support for their current insurance regimens.

In short, Republicans in Congress are largely left to themselves to figure out which direction to head, with the current lack of leadership from the White House on the matter. Trump seems willing to talk and consider any proposal from anyone, but at the same time he appears reluctant to take the lead on this. Perhaps it’s because of the political risks involved or his own personal concerns regarding these specific reforms.

Speaker Paul Ryan and Majority Leader Mitch McConnell are moving forward and fighting for the Party’s stated goal of ending the law. They face an uphill challenge in the Senate, where more liberal Republican Senators like Collins and Murkowski may defect at a moment’s notice, not to mention convincing enough Senate Democrats to go along with the change. They believe that by moving forward quickly, they will play a game of chicken with wavering Republicans, in hopes that they won’t stand against them if push comes to shove.  Republicans’ “now or never” approach is seen by many leaders as their best chance to break through irreconcilable differences.

For all of the talk from the White House and Congress, the amazing aspect about all this is how little consensus has been achieved by the GOP. On major policy issues, even as basic as how to provide tax credits to individuals to buy health care, there is very little agreement. Unless Trump takes the leadership reins on this issue, this process may quickly devolve into a game of herding Capitol cats.