Congressional Republicans, who ran against Obamacare through four election cycles, have spent most of the past year running away from it. But they are finding the law hard to escape.
Democrats who once shied away from Obamacare now can’t stop talking about it. They are blaming Republicans for the next round of premium increases that will become finalized in the weeks leading up to the November elections.
Republicans will justifiably respond that Obamacare is a mess they didn’t make. Voters may nevertheless hold them accountable for not cleaning up that mess, despite years of campaign promises.
Congress should keep those promises, according to a group of conservative policy analysts, state-based think tanks, grassroots organizations, and GOP governors and state legislators. Tuesday, a group of them announced support for the Health Care Choices Act, a proposal that would repeal Obamacare entitlements and replace them with grants to states to finance consumer-centered reform.
The plan is innovative and bold. The ill-fated bills Congress considered last year kept the federal structure of Obamacare with relatively minor modifications. For example, those proposals modified the federal tax credits that are at Obamacare’s core; the Health Care Choices Act would repeal them. And while last year’s bills would have reduced federal spending on Medicaid coverage of able-bodied adults, the Health Care Choices Act would scuttle the Medicaid expansion policy entirely.
The proposal resembles the successful welfare reform of the 1990s, which repealed the individual entitlement to cash benefits and replaced it with grants to states to assist the needy. The Health Care Choices Act does the same thing with health care, but on a much grander scale. It would repeal an open-ended federal entitlement program expected to cost $1.6 trillion over the next decade and replace it with a block grant. It is welfare reform on steroids.
Block grants are not blank checks. Like welfare reform, which required states to implement policies to encourage work and reduce dependency, the Health Care Choices Act would require states to pursue two important goals: reducing costs and increasing health care choices.
States would be required to spend a portion of their federal allotments on meeting the medical needs of the sick without saddling the healthy with exorbitant premiums. Other stipulations would prevent states from using the money to expand Medicaid or to warehouse the poor in state-contracted managed care plans. States would have to provide low-income people assisted through the through the block grant, as well as Medicaid and State Child Health Insurance (CHIP) recipients, the option of applying the value of their assistance to the plan of their choice. Think of it as school choice for health care.
The new money would be provided through the CHIP statute which, unlike Obamacare, includes permanent restrictions on the use of funds for abortion. Within those broad guidelines, states would design their own programs, determining who is eligible for assistance and what they’re eligible for. They would be released from Obamacare regulations on essential health benefits, age related premium variation, and the requirement that insurers enroll the sick and healthy in the same insurance pools. Repealing these regulations would allow states to repair or ameliorate much of the market dislocation Obamacare produced.
In short, the Health Care Choices Act would dismantle two of Obamacare’s pillars and weaken the third: Obamacare’s individual entitlement would be abolished, the employer mandate (like the individual mandate) would be repealed, and federal insurance rules would be diluted.
Some conservatives look at the proposal’s health care reform donut and complain about the hole. They have particularly faulted the plan for not repealing Obamacare’s pre-existing condition rules.
Republican reactions to last week’s Justice Department motion in a lawsuit that seeks to invalidate these rules is instructive. Democrats attacked the Trump administration – and Congressional Republicans – for opposing pre-existing condition protections.
To stanch the political bleeding, Senate Majority Leader Mitch McConnell declared, “Everybody I know in the Senate – everybody – is in favor of maintaining coverage for pre-existing conditions.”
McConnell’s colleagues pointedly did not race to the microphones to distance themselves from their leader. Nor are scores of House and Senate conservative incumbents campaigning on a promise to repeal the popular pre-existing condition requirements.
The message is clear: repealing that requirement does not enjoy anything like majority support even in a GOP Congress. For some conservatives, that is reason enough to leave Obamacare in place. If Congress can’t pass a perfect bill, they argue, then it shouldn’t pass anything at all.
A growing cadre of conservatives is unwilling to accept the status quo. They are pushing back against congressional inertia and conservative fatalism as they urge Congress to roll back an Obamacare regime that continues to raise costs and constrict health care choices.
They view the Health Care Choices Act’s repeal of Obamacare’s entitlements and devolution of power from Washington to the states not as the final word on health care reform, but as an essential component of a broader effort. Expanding health savings accounts is part of that effort. Promoting innovative approaches like health-sharing ministries and direct primary care is another. Trump administration regulatory proposals to allow small businesses and independent contractors form health insurance purchasing groups across state lines also are part of it, as is its plan to expand the sale and renewal of short-term, limited duration policies.
Conservatives who back the Health Care Choices Act prefer real progress to theoretical perfection and the inaction it induces. They also argue that it is politically better for Republicans to confront Obamacare than to be blamed for its failures.
Republicans are stuck in a Nash equilibrium on Obamacare repeal. Conservative firebrands, Republican moderates and congressional leadership – each for very different reasons – are content to make Obamacare repeal the new balanced budget, something they talk about to mine money and votes from their base, but never seriously pursue.
The millions of families and thousands of small businesses suffering under Obamacare deserve better.