What Went Down On Health Care This Week

Dan’s earlier post about whether the “skinny repeal” will be popular brings up an interesting point about the Affordable Care Act: Most of the law’s provisions have polled highly throughout its existence — in fact, the individual pieces have been more popular than the law overall. Why? Most of the items in Dan’s list below are about increasing coverage for Americans (e.g., expanding Medicaid or covering pre-existing conditions) or taxing businesses or wealthier people (e.g., the employer mandate or the Medicare payroll tax). The reason the ACA has polled poorly overall at times is a lack of support for the individual mandate — the part of the law that forces most Americans to buy insurance or pay a fine. Americans seem to like the law as long as they don’t have to pay for its benefits. Put another way, opposition to the ACA hasn’t been an ideological objection to larger government — it’s been an objection to paying for larger government. The problem, of course, is that for there to be more services, there must be a way to pay for those services. The mandate is that payment mechanism. That’s part of the reason why many policy experts argue that “skinny repeal,” which eliminates the mandate, would be a policy disaster.

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.