//  7/27/17  //  Commentary

Cross-posted from Balkinization

With two strikes thus far on more substantial Obamacare repeal efforts, the Senate seems headed for the so-called "skinny" repeal option, which it appears would repeal the individual insurance-purchase mandate, along with the employer mandate and the medical device tax, and leave everything else in place.

This repeal is hypocrisy of the highest order.  For starters, the repeal was supposed to fix what Trump likes to call the "Obamacare disaster."  What exactly is that disaster?  If it's Medicaid, this bill isn't going to touch it.  (And it's not Medicaid: It has been documented that the Medicaid expansion (whether you like that program or not) is working quite well.  For additional proof, just look at all the GOP resistance to cutting it and the number of red states that have expanded their programs). The "disaster" is the insurance markets--premiums that are too high, not enough competition on the exchanges.  That "disaster" as I have detailed elsewhere, was a tragedy mostly of the Republican party's own making.  Legislation and litigation by the Republican controlled Congress sowed uncertainty into the insurance markets and shut off critical insurance stabilization funds that the ACA as drafted provided.

To be sure, the ACA isn't flawless.  The amounts set to subsidize individual purchase of insurance were set too low originally (which is one reason premiums feel too high for many).  But the Congress never fixed that either, and it sure isn't doing so now.

Instead, the skinny repeal would exacerbate the very problem the Republicans claim they are repealing the ACA to address. Health experts, republican governors, insurers, hospitals--you name it--agree that repealing the mandate will cause premiums to rise even further and insurance markets to descend into even more fatal instability.  Why?  You can't make insurance more generous without giving something back.  The ACA gives something to the American people at the insurance industry's expense: it changes the way the industry does business by requiring insurers to take all comers at essentially equal rates regardless of health risk. In return, it gave the insurers more customers and an expanded, healthier, risk pool.  Taking away the mandate without repealing the generosity puts the insurance industry in the position of having to find some way to fund this generosity or risk collapse.  

Of course, everyone  (read: voters) likes the generosity--no one wants to be turned away from health care because they have cancer or some other condition.  The Republicans are unwilling to take the direct heat for taking those benefits away from the American people, so they are going to further sabotage the insurance markets and hope the American people are sufficiently ignorant that they will blame it on Obama instead.

But don't take my word for it. If there are any doubts about what effect the skinny repeal will have, consider this statement from the Republican amicus brief filed in the Supreme Court in the 2012 (unsuccessful) challenge to the individual mandate.  The brief argued the ACA could not survive without the mandate--that millions of Americans would lose insurance and access to care and that insurance premiums would rise dramatically.  Twenty-seven of those Senators are still in the Senate. In their own words:

"The individual mandate is at the heart of the PPACA, and the remainder of the statute necessarily depends on its inclusion because without the mandate, the statute’s reforms cannot work as intended. Indeed, the proponents of the PPACA knew at the time Congress considered the legislation that without the mandate both the number of uninsured and the price of premiums would skyrocket. In short, without the mandate, Congress’ attempted solution to the twin problems of health care coverage and costs  disappears." Br. of U.S. Senators at 10.

(That's what the Congressional Budget Office said today, too.  It projected the skinny repeal would cause premiums to rise approximately 20%  and 16 million people to lose insurance by 2026.)

To make matters worse, to satisfy Senate requirements concerning the amount of money the repealer must save, some have suspected the skinny repeal will also need to include a provision gutting the ACA's public health and prevention fund, and possibly also the community health centers fund, raiding that money to pay for the havoc the bill will wreak on the insurance markets.   Cutting public health and prevention money, throwing millions off the insurance rolls, and raising premiums--at the very same time Republican senators themselves have clamored for more funds to address the national opioid crisis?  At the very same time they claim to be rescuing America from a health policy disaster?

It's worse than hypocrisy. It's irresponsible.

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