As we reported last Thursday, even as a reported deal is said to be coming together, the likelihood of a vote this week seemed ambitious-to-remote. Leadership sources cautioned that the full conference would need to see bill's new language and discuss the new provisions as a group before any legislative steps were taken -- and that the very first step was a House Republican conference call over the weekend. That call took place, and details have been somewhat scarce. All that really emerged was that progress is being made and the relevant committees may start to "draft something" soon. But the "primary focus" of this week is getting the government funded and avoiding a Democrat-triggered partial federal shutdown, sources say. So where does that leave the revamped American Health Care Act? We may see movement early next month, according to a few players in the current negotiations. Via Bloomberg:
“Health care may happen this week, it may not,” White House Chief of Staff Reince Priebus said on NBC’s “Meet the Press” on Sunday. “We’re hopeful it will.” Representative Dave Brat of Virginia, a member of the conservative House Freedom Caucus, said the health-care vote will more likely come in early May. “The odds of that are pretty good,” Brat said in an interview on Friday with a Richmond radio station. Also suggesting that timeline was Representative Mark Sanford of South Carolina, who said on CNN’s “State of the Union” on Sunday that finding a way to vote in the coming week would be “awfully tough.”
One very clear message coming out of the call, as reported by multiple sources is that House leaders will take pains to avoid replicating last month's embarrassing spectacle in which a vote was called before they had a solid whip count:
Another well-placed source confirms to Townhall that "[Speaker Ryan] was clear there will be a vote only when we know we can pass the bill. The votes will drive the timing." In our most recent analysis of these developments, we explained why even if previously recalcitrant House Freedom Caucus members were brought into the fold with the latest alleged deal, skittish Tuesday Group moderates might get scared off by coming Democratic attacks over the loosening of certain health care mandates. Surveying the situation, conservative healthcare wonk Avik Roy writes that the GOP is following in the footsteps of Democrats' misplaced obsession with pre-existing conditions, at the expense of focusing fostering a marketplace in which affordable coverage is more widely available:
Obama and other Democrats made it sound like there were tens of millions of Americans going uninsured because cruel insurers were refusing to cover them. The Obama administration even put out a report titled “At Risk: Pre-Existing Conditions Could Affect 1 in 2 Americans: 129 Million Could Be Denied Affordable Coverage Without Health Reform." That's ludicrously dishonest. Here’s why. First: prior to Obamacare, the vast majority of Americans with health insurance were already in plans that were required to offer them coverage regardless of pre-existing conditions. Employer-based plans were required to offer coverage to everyone regardless of pre-existing conditions. So were Medicare, Medicaid, and other government programs like the VA. Employer- and government-based plans, prior to Obamacare, represented 90 percent of Americans with health insurance. The other 10 percent were people buying coverage on their own, on the individual market. In most—but not all—states prior to Obamacare, people buying coverage on their own could, in theory, be denied coverage for a pre-existing condition. That gets us to point number two: that in practice, a tiny percentage of Americans were being denied coverage due to a pre-existing condition prior to Obamacare...
...The moderate Tuesday Group, co-chaired by Rep. Tom MacArthur (R., N.J.), appears to be much less interested in subsidizing the working poor, and much more interested in preserving Obamacare’s regulations around pre-existing conditions. A one-page outline of a proposal by MacArthur obtained by Politico focuses exclusively on preserving Obamacare’s insurance regulations, while offering a “limited waiver option” to states to ask Washington for flexibility around essential health benefits and some insurer pricing practices. The proposal does not address the AHCA’s deficiencies with regard to coverage for the working poor, the problem that the Freedom Caucus’ Meadows was trying to address...What’s really happening here is that all of that exaggerated Democratic rhetoric about pre-existing conditions worked. Many middle-class Americans with employer-based or government-sponsored insurance have been persuaded by Democrats, inaccurately, that repealing Obamacare’s regulations about pre-existing conditions directly affect them. GOP moderates are responding directly to these constituents. On the other hand, House GOP moderates appear to be more comfortable with the fact that the GOP bill, in its current form, would price millions of low-income, near-elderly Americans out of the health insurance market. That may seem counterintuitive. But it is a reflection of eight years of deceptive pro-Obamacare advertising.
The full piece is worth a read. Roy's conclusion is that he believes ensuring affordable access to care for certain demographic cohorts ought to be the policymaking priority, but it isn't right now. He seems resigned to the notion that the challenge won't be adequately addressed in the House legislation, sighing, "it will be up to the Senate to fix these problems. Hopefully, they’re up to the task." On another crucial policy front about which I've been writing for months now, right-leaning health policy experts have been grappling with how to help guarantee drastically increased participation from so-called healthy "young invincibles" in the individual market. The concern that some people have raised is that the AHCA does not rectify Obamacare's core adverse selection flaw, which is leading to a steady death spiral-type swirl of fewer participating carriers and higher premiums due to a disproportionately sick and expensive risk pool. The GOP bill encourages continuous coverage among younger and healthier consumers by allowing insurers to apply a 30 percent surcharge to anyone who seeks to gain coverage after a gap. The idea is to guard against free riders who wait to get sick or injured before signing up for a plan, knowing that insurers are now required to take them on with pre-existing conditions.
But skeptics have argued that the same unsustainable dynamic remains in place within the Republican proposal. If Obamacare's individual mandate tax is gone, but other core regulations stay the same, why wouldn't younger people still put off buying "insurance" until after they needed it? Who cares if they have to pony up for a relatively small surcharge for one year? The trade-off is worth it. In some ways, the Republican plan could make the adverse selection problem even worse. (For what it's worth, top Republicans have told me that insurers have endorsed the existing surcharge idea as viable). James Capretta has been plugging away at this problem in a series of essays, with one suggestion being considering a longer duration of the surcharge depending on how long a new would-be consumer had gone uninsured. In a new Wall Street Journal op/ed cowritten with Lanhee Chen, Capretta serves up another possible solution:
ObamaCare aims to help people with pre-existing conditions by prohibiting insurers from charging them higher premiums or restricting their coverage. The GOP wants to provide similar protections, but only to those who stay enrolled. People who opt out would pay a penalty when they try to re-enter the market. In that case, Congress should also help policyholders avoid breaks in coverage. Lawmakers could require insurers to offer products whose premiums match the value of the federal tax credits. If the basic, age-adjusted federal tax credit for a 40-year-old man in a given state is, say, $3,000, then every insurer in the state would have to make a policy available for such customers with a $3,000 premium. Insurers would adjust the upfront deductibles in these plans as necessary to ensure that the premium equals the credit.
Most consumers in the individual market would thus have the option to get an insurance plan with no cost to themselves. This no-premium coverage would necessarily have higher deductibles than costlier options, but it would provide financial protection against expensive medical claims, which is the primary purpose of insurance. As with other benefit programs, many Americans wouldn’t use the credits for which they are eligible, out of inertia or lack of information. To solve that problem, the states could automatically place eligible households into the no-premium option, randomly assigning them to one of several competing insurance plans and then notifying policyholders of their coverage. Opponents will argue that automatic enrollment infringes on personal liberty. But people placed into such coverage would be free to opt out or to select an option that better suits their needs. Few people opt out of employer pensions when they are placed into them automatically, and no-premium insurance would impose no cost on the enrollees.