What Went Down On Health Care This Week

With all the talk of amendments, CBO scores and threats against Alaska, it’s easy to lose sight of the bigger picture, which is striking. For years, Republican officials have been pointing to problems with the ACA marketplaces for individual insurance as evidence of the Affordable Care Act’s failure. In May, the House passed a bill that would provide short-term stabilization funding for the exchanges while transforming and deeply cutting Medicaid later in the decade. But the Senate’s preferred solution flips the House’s bill on its head. The “skinny repeal” is likely to further destabilize the exchanges while leaving Medicaid untouched. To put it more starkly, the proposals advanced by House and Senate Republicans embed different, even opposing, ideas about the underlying policy problem that needs solving. The main thing they have in common is that they both plausibly address the GOP’s political need to attack the ACA.

We still don’t have the actual text for the “skinny repeal” bill, but it’s been reported to include provisions that get rid of the individual mandate, the employer mandate, and a tax on medical devices. As Marc Goldwein at the Committee for a Responsible Federal Budget pointed out, if that’s the bulk of the bill, it might not comply with the rules of reconciliation. According to the CBO tables released last night, which show the budgetary effect of cutting those three provisions (and a couple of public health funds), that bill wouldn’t cut enough money from the budget to be able to pass with 50 votes, so it would require support from 60 senators.

The Senate is reportedly moving toward voting on a “skinny repeal” which would end the ACA’s individual mandate, its employer mandate, and its medical device tax. Yesterday, Harry pointed out one of the political virtues of this repeal strategy: It targets the individual mandate, one of the least popular elements of the ACA. While some in the GOP leadership clearly see the proposal as just a way to get to a conference committee, anything that is passed by the Senate has a real chance of becoming law. That said, the Republicans shouldn’t leap to the conclusion that a “skinny repeal” would be as popular as the individual mandate is unpopular. Back when the ACA was being adopted and implemented, some Democrats argued that the Affordable Care Act would become more popular over time because its component parts polled better than the legislation itself. The table below, for instance, comes from a 2011 Kaiser Family Foundation poll that asked about support for 15 separate pieces of the ACA. As you can see, the law’s individual elements poll very well — even the Medicare tax on high earners gets 59 percent favorable ratings.

The ACA polls better in pieces

Share of survey respondents with favorable views of ACA provisions, 2011

PROVISION	FAVORABILITY
Easy-to-understand health plans	84%
Small business tax credit	80
Financial help to low/moderate income Americans	75
Medicare donutnut hole	74
Independent reviewer	74
Expand Medicaid	69
Pre-existing conditions	67
Government review premium increases	66
Eliminate co-pays and deductibles	64
Employer mandate	63
Insurance company rebates	60
Increase Medicare payroll tax	59
Increase premiums of high income Medicare people	57
Mandatory minimum package benefits	53
ACA overall	37
Individual mandate	35

But notice that the law’s overall favorability — 37 percent — is just a shade above that of the lowest-rated element, the individual mandate, which polls at 35 percent favorable. (Remember, this Kaiser poll is from 2011; the ACA has become more popular since then.) In other words, citizens’ overall evaluations of the ACA are in no way an average of their feelings on the law’s individual elements. And if the “skinny repeal” leads to rising premiums and insurers’ withdrawal from the marketplaces, it’s unlikely to be as popular as the public’s opposition to the individual mandate would imply. In assessing bills, the whole picture is rarely a sum of the parts. Tiger Brown, Saleel Huprikar and Louis Lin provided research assistance.