Opinion: Where House Republicans and Democrats might actually agree on preexisting conditions

House Republicans kicked up a healthcare furor by proposing to let states remove the ironclad protections in Obamacare for millions of Americans with preexisting conditions. But their approach to the issue is, on one level, not far removed from what progressives have long advocated.

Stick with me here, it’s not as ridiculous as it sounds. No, the Republicans’ repeal-and-replace bill, the American Health Care Act, does not call for a single-payer system, universal coverage or anything so warm and fuzzy. What it does propose, however, is to dun federal taxpayers to make sure the sickest and riskiest Americans can obtain coverage.

Let that sink in for a moment. The same people seeking to cut Medicaid’s budget by 25%, leave millions of Americans unable to afford insurance and bring bankruptcy-inducing policy limits back to employer health plans would also pour billions of federal tax dollars into states to subsidize coverage for people who cannot get affordable policies from private insurers because of preexisting conditions or high-risk jobs.

This makes a certain amount of sense. To many Republicans, the problem with healthcare today isn’t that medical bills are too high. It’s that insurance premiums are too high, specifically for middle-income Americans not covered by large employer plans. The House GOP’s two-part solution is to offer tax credits to all but the highest-income households, not just the poor (although in a way that will leave many working-class Americans uninsured), and, if states decide to go this direction, remove the cost that sick and risky people impose on healthy people in the individual and small-group markets. At least two Republican governors have already expressed an interest in doing just that.

Some of the earlier proposals floated by the House GOP would simply have ghettoized the sick who didn’t have continuous insurance coverage, consigning them to state high-risk pools whose history of failure rivals that of the Clippers. But in order to keep enough moderates on board, the House added amendments throwing $23 billion more at the state pools so that folks wouldn’t be priced out of the market or lose access to costly forms of coverage (e.g., maternity and mental-health care).

If Republicans really understand what they’ve proposed, then they’ve reached a place not too far removed, philosophically, from where Democrats are. Because Democrats — and Obamacare — are all about helping the chronically ill and others who face big healthcare bills pay for their insurance.

The mechanism Democrats used in Obamacare was “community rating,” the requirement that insurers charge all similarly aged people in an area the same premiums. That mandate spread the risk and cost of medical care from heavy users to light ones — in other words, from sicker people to healthier ones. The result in some regions, however, was too much cost being spread among too few insurance buyers, contributing to big losses by insurers and eye-popping premium increases.

House Republicans are, in a way, taking that approach to the logical next step by spreading the healthcare costs of those with preexisting conditions onto a much bigger group: all U.S. taxpayers. The other main difference is that the House GOP bill wouldn’t guarantee these folks a subsidy large enough to make their premiums affordable. Instead, the bill’s supporters are simply claiming that the bill includes enough money to pass that test for 10 years. Critics, including The Times’ editorial board, say it doesn’t.

In a functional legislative body, Democrats and Republicans would have seen the seeds of a bipartisan compromise there. Both sides say they want to address rising premiums and losses that are driving some insurers out of selected markets. Both sides say that people facing high healthcare costs and exorbitant premiums should be subsidized so they can afford coverage. It should come down to a question of how to do these things efficiently, effectively and reliably.

Instead, we may never get past the split between Republicans and Democrats over who else the public should subsidize in the individual and small-group markets, and how much it should cost: Impoverished but able-bodied adults without children? The working poor? The middle class? Older people with high incomes?

Those are important questions too. And honestly, a bipartisan compromise on a healthcare law rewrite is no more likely than the Earth suddenly spinning the other direction. Republicans have built up far too much momentum on “repeal and replace,” they’ll either make it happen on their own or fail on their own. Nevertheless, the House GOP cleared a small patch of common ground, if either side is interested in trying to cultivate it.

jon.healey@latimes.com

Twitter: @jcahealey