Republicans and Democrats in Congress are sniping at each other over the failure to include a provision to stabilize the Affordable Care Act markets in last week's omnibus spending bill.
But there's really no mystery about the nature of the real obstacle: It was Republican insistence on expanding an antiabortion measure to private healthcare plans. The GOP proposal would have placed federal law in direct conflict with laws in California and at least three other states that require nearly all health plans to cover abortions.
This is a measure Republicans and other antiabortion politicians have been trying to squeeze into law since the ACA was debated in 2010; they've failed every time.
That's reason to be skeptical about GOP accusations that Democrats deliberately scuttled the rescue bill to make hay over premium increases that could emerge later this year, just before the midterm elections.
"The other side believes that if they can block this proposal and keep it from becoming law, the premium increases surely to come will fall upon the Republican Party, and will give them the opportunity to take back the House and regain the majority in the Senate," groused Sen. Lindsey O. Graham (R-S.C.). "That, to me, is sad."
Spare us the dudgeon, Sen. Graham, at least until we take a look at what you and your fellow Republicans were aiming to do.
It's proper to note at the outset that the ACA rescue bill scuttled by this dispute was a poisoned chalice — on the surface it would have stabilized the ACA market, but only at the expense of driving hundreds of thousands of Americans out of the market and raising rates for many middle-income buyers. More on that in a moment.
Under the Hyde Amendment, which is attached to federal spending bills every year, federal funds can't be directly spent on abortions, except in cases such as rape, incest or to protect the health of the mother. The amendment applies to healthcare programs directly funded by the federal government, including Medicaid, private health plans for federal employees and women in federal prisons, in the Peace Corps and the military.
As part of their ACA repeal-and-replace campaign, Republicans consistently tried to expand the ban to private insurance plans offered via the ACA marketplaces. The goal was to forbid federal premium subsidies from being used to buy health plans that covered abortion, even if that coverage wasn't used by the enrollee.
As The Times reported last year, when this scheme originally surfaced, the provision would have made virtually all insurance plans in California ineligible for subsidies. This would amount not only to a general attack on women's reproductive rights, but one aimed specifically at lower-income women—those reliant on subsidized health plans and lacking the private resources to obtain abortion services on their own. California's law is the most comprehensive, but the rule change also would affect plans in Oregon, New York and Massachusetts, which don't allow abortions to be treated separately from other medical procedures.
Under-the-table restrictions on abortion coverage similar to the GOP measure have been enacted in many states, according to the Guttmacher Institute. Limitations on abortion coverage in ACA plans are in effect in 26 states, of which two (Louisiana and Tennessee) forbid any abortion coverage; the rest allow it under circumstances including rape, incest, and endangerment of the mother's health. Abortion coverage is restricted in insurance for public employees in 20 states, and 11 restrict it to one degree or another in all private health plans written in the state.
This history makes clear that Republicans shouldn't have been surprised that their abortion rider would be a deal-breaker for the ACA rescue bill. One can only assume that they put it in deliberately to provoke Democratic resistance, which they could cynically exploit.
The stabilization bill scuttled last week was introduced by Sens. Lamar Alexander (R-Tenn.) and Susan Collins (R-Maine). It would have restored cost-sharing reduction payments for insurers and provided federal funds for reinsurance in the individual market, which would reduce costs for insurers and therefore presumably bring down premiums.
The cost-sharing reduction payments, it may be remembered, are those that compensate insurers for the reductions in deductibles and co-pays given to the lowest-income families buying insurance through the ACA. President Trump canceled them last year in the fantasy that this would cause Obamacare to "implode."
His action did cause pain for some insurers, but most states provided a workaround for the 2018 plan year and thereafter by allowing insurers to fold the uncompensated costs into the premiums for benchmark silver plans. This allowed them to hold premiums for plans in the other ACA tiers steady, and in fact drove up federal costs because federal premium subsidies are based on those benchmark plans, so the subsidies were pushed higher. Trump's action ended up making ACA insurance more affordable for thousands of families—the opposite of his goal.
In other words, cost-sharing reduction payments became a non-issue after 2017. By restoring the those payments, the Alexander-Collins plan would, ironically, lead to higher costs for many ACA buyers, especially those earning too much to be eligible for federal subsidies. The number of uninsured Americans would increase by as many as 1 million people by 2021, according to the Congressional Budget Office.
Alexander-Collins also would have appropriated $30 billion over three years for state-based reinsurance programs, but that would not have relieved premium pressures on unsubsidized buyers, according to the Center on Budget and Policy Priorities.
To sum up, it was Republican maneuvering that killed the GOP's own stabilization plan, which would have done precious little to stabilize the ACA marketplace anyway. Maybe the Republicans did everyone a favor, after all.