We may never know how many Republicans in the U.S. Senate would have voted against the latest ill-conceived and disruptive proposal to “repeal and replace” the Affordable Care Act. But we know the three whose public opposition kept the measure from reaching the Senate floor this week — Susan Collins of Maine, John McCain of Arizona and Rand Paul of Kentucky. Although they disagree sharply over what to do about the ACA, they all deserve the country’s thanks for stopping lawmakers from heedlessly leaving millions of lower- and middle-income Americans unable to afford coverage and sending the market for non-group policies into a death spiral.
The proposal by Sens. Lindsey Graham (R-S.C.), Bill Cassidy (R-La.), Dean Heller (R-Nev.) and Ron Johnson (R-Wis.) would have ended the subsidies in the ACA for low- and moderate-income Americans’ private insurance premiums as of 2020. It also would have terminated the extra funding the ACA provided states that had extended Medicaid to more low-income adults. Instead, the measure would have provided states a smaller amount of money — about $240 billion less between 2020 and 2026, by one estimate — in the form of block grants to spend on unspecified subsidies for health insurance and care. And the dollars would have been shifted gradually from states that had expanded Medicaid to the ones that hadn’t, a change that was projected to cost California almost $140 billion over the coming decade.
Supporters of the proposal never offered a good reason for this new approach. Saying they hoped to encourage state innovation, they ignored the decisions states had already made about healthcare policy as well as the differences in healthcare costs from state to state and city to city. Professing to be vexed by rising premiums and Medicaid spending, they did nothing to address a key source of the problem, the rising cost of care. Claiming to protect people with preexisting conditions, they pushed a convoluted proposal that would have let states lift almost all the safeguards the Affordable Care Act had provided for people who are already sick. So determined to kill the act, they charged ahead with a plan simply because it had a chance to attract 50 GOP votes, no matter how much damage doctors, hospitals, insurers or industry analysts said it would wreak on the system.
Taking a truly principled stand, Collins opposed the measure even after its sponsors tossed her state an additional $700 million, saying she worried about the cuts to Medicaid and the removal of protections for people with preexisting conditions. Both she and McCain rightly blasted the procedural shortcuts that kept industry experts (and Democrats) on the sidelines. For his part, Paul complained that the measure’s reduced aid for healthcare was still somehow too generous.
Graham-Cassidy-Heller-Johnson was packaged as a budget bill for fiscal 2017 in order to avoid a certain Democratic filibuster, and as such had to pass by Saturday, when the fiscal year ends. But the measure’s demise won’t end the debate over the Affordable Care Act, whose problems still require Congress’ attention.
It should be noted that those problems aren’t as ruinous as President Trump and congressional Republicans claim. Some insurers have withdrawn from the state insurance “exchanges” the ACA created for people not covered by large employer health plans, and premiums in some of those exchanges have jumped — in part because of the uncertainty injected by Congress and the Trump administration, which is still trying to undermine the law. But every region will still have at least one insurer offering coverage through the exchange, and the premium increases will be offset by federal subsidies for the vast majority of people shopping there.
Nevertheless, in less densely populated areas, healthcare costs are being spread across too few people with insurance. Meanwhile, the Trump administration has threatened to stop reimbursing insurers for covering the out-of-pocket costs of low-income customers, as the ACA requires. To hold down premiums in the exchanges, Congress should find a way to spread costs more broadly and guarantee the reimbursements for out-of-pocket costs. And the Trump administration needs to stop treating the exchanges like the enemy and focus instead on helping people get coverage.
With Graham-Cassidy-Heller-Johnson off the table, senators should resume the bipartisan efforts to stabilize the markets that the GOP leadership snuffed last week. And although Paul may still blanch at spending money on healthcare subsidies, most of his colleagues were ready to vote for a proposal that would have dedicated tens of billions of tax dollars to subsidizing coverage and care. It would be hypocritical and cynical for those Republicans to oppose efforts to help the exchange customers who are feeling the pinch now.
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