Obamacare

Senate Republicans Add Individual Mandate Workaround to Health Care Bill

It's one more way the GOP repeal bill resembles Obamacare.

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KEVIN DIETSCH/UPI/Newscom

Despite being billed as an Obamacare repeal plan, the health care bill released last week by Senate Republicans kept many of Obamacare's core elements in place, including federal regulations restricting health insurers from charging based on preexisting conditions and income-based subsidies for individuals purchasing health coverage on the individual market. But it lacked one of Obamacare's notable features—the individual mandate to purchase health insurance.

From a political perspective, this was not surprising. Republicans have spent the last seven years criticizing the health law's mandate. But as a matter of policy, it was an unusual decision: Over the last several decades, several states have attempted to implement preexisting conditions regulations without a mandate.

Every single one has seen their individual insurance market melt down in the space of a few years. With regulations but no mandate, people wait until they are sick to buy coverage, meaning that health insurers end up covering a smaller group of sicker people. This raises premiums, which pushes healthier people out of the market, which raises premiums further, and the cycle continues until premiums are unaffordable and insurers, unable to make money, leave the market: in other words, a death spiral.

This afternoon, Senate Republicans updated their health care bill, the Better Care Reconciliation Act (BCRA), to include a provision that is not a mandate, but is intended to act as a substitute for it. It's a backdoor mandate—a workaround designed to fulfill the same function. It's another sign of how much of Obamacare's individual market design Republicans have borrowed for their own bill.

Instead of a fine for going uncovered, as in Obamacare, the Senate GOP bill now includes a continuous coverage provision: Anyone who goes without coverage for more than 63 days must wait six months before getting coverage again. The goal, as with the mandate, is to create an incentive for health people to buy coverage and maintain it, by penalizing if they don't.

It doesn't take too much work to imagine how a provision like this might end up being weakly enforced, if only for political reasons. Obamacare already includes an open enrollment period, outside of which people are not allowed to buy coverage—at least in theory. In practice, there are numerous exceptions, and insurers have complained that those exceptions have allowed large numbers of people to jump on and off health plans throughout the year, obtaining coverage only when sick. In turn, insurers respond by raising premiums. If the six month waiting period goes into effect, it's likely to lock some sick people out of coverage, and the result could be the creation of loopholes that weaken the provision's effectiveness.

It's one of the many flaws inherent in the design of both Obamacare and the Senate bill: The political unpopularity of the mandate, and of mandate alternatives like this, makes it difficult to maintain the regulatory balance that is supposed to make the whole system work. In any case, it's one more way in which the health care bill put forward by Senate Republicans resembles a skimpier version of the bill it is supposed to repeal, and further evidence that Republicans aren't repealing the health law so much as putting their own awkward stamp on it.

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  1. This resembles nothing more than GOP shoving spinach around the plate to waste time in hopes that they can finally get permission to do what they really want to do – deliver goodies to the donor class in order to get their fundraising back up for the 2018 election.

  2. “The business of Progressives is to go on making mistakes. The business of Conservatives is to prevent mistakes from being corrected”

    -Chesterton

    1. GREAT QUOTE!!!!

  3. Christ, what assholes.

    1. If only we could comment at the blog-level rather than only at the thread-level, you wouldn’t have to repeat yourself in every article…

  4. I have it on good authority from reliable sources that the AHCA is good because it repeals the individual mandate AND NOTHING ELSE HAPPENED.

    1. You must have been talking to Ken.

      1. You don’t so much ‘talk to’ Ken as find yourself lulled into a coma by a neverending stream of repetitive droning by Ken.

        1. He’s actually pretty clever. Once you’re in a coma it’s the perfect opportunity for him to go through your wallet. Well, not yours specifically, Hugh. As we all know your wallet contains nothing but flower petals and partially-chewed Nicorette.

          1. I also have a Pluto Nash promotional condom.

  5. Better Assistance Reconciling Affordable Care and KKKongress Act


  6. Over the last several decades, several states have attempted to implement preexisting conditions regulations without a mandate. Every single one has seen their individual insurance market melt down in the space of a few years.

    Look, this is never going to work without a mandate. The popular parts of the bill make the unpopular parts of the bill necessary. That’s a given.

    This is proof positive that what the public wants is impossible in the form that the public wants it. Instead of saying ‘no, it’s impossible, lets do what we know works’ the Republicans cave to the idiots and take ownership of a program that will inevitably destroy our health system.

    Kudos, assholes, for not doing the one thing you were elected to do (no one was saying ‘repeal and replace’ until after they won back the majority/presidency). While it’s certain they don’t have the votes to do what they promised, this is pretty literally the opposite of doing what they said. That can’t be ignored, while doing ‘nothing’ would have at least been honest.

    It appears the Republicans are now the evil party, and Democrats have become the stupid party. Nice. That happens, from time to time.

    1. Look, this is never going to work without a mandate.

      which is exactly what every other country on Earth has discovered about healthcare. The difference is that most others have realized that if you have to mandate, then do it directly via taxes and overt rationing of the tax-paid stuff – not via some cronyist pricing distortion of ‘insurance’.

      1. Singapore, brah! It’s hard to call what they’re doing free market (actually, it’s impossible to call it that), but it’s not like any other single payer plan either. It’s very interesting.

        I learned the other day that there’s only 2 countries where the government completely controls healthcare: Canada and the UK. Everyone else still has private insurance companies playing a major roll, usually along with a bare-bones singe-payer option (or something that acts like it).

        1. Do you think what Singapore is doing could scale?

          I think a lot of what they do works because of the size.

          Yew also conditioned that whole country in a very particular way.

          1. I don’t know. I’ve heard economists say “don’t use Singapore as a model for anything,” since it’s so anomalous is so many ways. Honestly, even if what they’re doing would scale, I think it’d be politically impossible to use here.

            The reason I bring it up is I think there’s lots of interesting ways to approach healthcare. It’s not just 1) What we’re doing now, 2) No rules, completely free market, or 3) single payer.


    2. It’s a backdoor mandate?a workaround designed to fulfill the same function. It’s another sign of how much of Obamacare’s individual market design Republicans have borrowed for their own bill.

      Anyone who goes without coverage for more than 63 days must wait six months before getting coverage again. The goal, as with the mandate, is to create an incentive for health people to buy coverage and maintain it, by penalizing if they don’t.

      And, for the record, this is miles different than the government claiming that it can force you to buy a particular product just because you happen to be alive.

  7. I will never disagree with the propositions that:
    1) so many Republicans in the Senate and the House are spineless weasels, and
    2) the majority of them are equally statist (just sometimes for different things).

    However, I have to continue to point out, that the reason the House and Senate keep producing shitty bills, is because the Dems (along with the “moderate” Reps) can stop anything more substantive from even getting an up or down vote. Should the few Senators and Congressman who really are for repealing Obamacare simply vote “no” on anything else?

    As most of us predicted, once the abortion known as “Obamacare” was passed, it was going to be difficult or impossible to get rid of.

    So for once Suderman, please place the blame where it belongs:
    1) Obama;
    2) The Dems who passed it; and
    3) The Dems and squishy Reps who won’t do anything substantive and positive to get rid of it.

    1. So for once Suderman, please place the blame where it belongs:

      LOL. He’ll get right on that.

    2. We really need a legislation sunset amendment. I think we could also benefit from requiring large supermajorities for anything to pass in the first place. If the vast majority of the nation isn’t on board, then it shouldn’t be able to pass. That way you don’t end up with ~50% of the population constantly trying to push the other ~50% around.

      1. I’m not so sure making even more Byzantine rules to slow down the speed and efficiency at which government moves is going to lead to good outcomes. I find it much more plausible that it just greatly exacerbates all of the existing problems.

        1. What problems would be exacerbated? Laws would only pass and persist if they enjoyed strong bi-partisan support. A lot of major regulations would sunset over the next few years. The war on drugs would end.

          1. If people actually want more bipartisan efforts, why do so many people use compromise as a dirty word?

            People get fed up with the general slowness of government, and being promised things in elections that never come to pass. So they elect more ideological, more rigid “crusaders” who theoretically won’t go back on stated positions. “The last person was a (democrat or republican) In Name Only! They compromised away their stated ideals for whatever whatever! What we need is a real (democrat or republican)!”.

            The newly elected, won’t-give-up politician goes to Washington and runs right in to democracy: compromise, trading this for that, and not quite delivering what they said. And the cycle continues.

            I think the auto-sunset rule is really interesting. Accumulation of regulation and outdated programs is definitely a problem. Supermajorities to pass anything worries me though – I do think the dynamic I described would become a lot worse.

            1. Virtually every conceivably needed piece of legislation was passed decades, if not centuries ago. The only thing government needs a quick pace in doing at this point is repealing laws. Auto-sunset takes care of that for it.

              And no, most people aren’t sitting around desperately waiting for government to “get to it”. Most people ignore government, except to the extent that partisan political affiliation is part of their identity.

  8. RE: Senate Republicans Add Individual Mandate Workaround to Health Care Bill
    It’s one more way the GOP repeal bill resembles Obamacare.

    The “Me Too” once displays its brotherhood with the democratic party.
    Instead of repealing Obamacare and deregulating the healthcare industry, the Me Too party shows the world once again it is embracing socialism a little more enthusiastically each day.
    The republican party turning the party of Lincoln into the party of Lenin slowly but surely.

  9. Just allow the insurance companies to provide reduced benefits for the first two (or whatever number gets negotiated) years if there has not been continuous coverage. That was working fine before Obamacare. I have all my nice little letters labeled ‘certification of continuous coverage’ stuffed in a file somewhere. I suspect the legislature cannot count as high as 63 days.
    No chance of course, that allows personal freedom and all that jazz.

  10. It’s a backdoor mandate

    “The Backdoor Mandate” was my nickname in college.

    1. It would be a good name for a bad band

  11. the Senate GOP bill now includes a continuous coverage provision: Anyone who goes without coverage for more than 63 days must wait six months before getting coverage again. The goal, as with the mandate, is to create an incentive for health people to buy coverage and maintain it, by penalizing if they don’t.

    I can’t wait to read 45,000 words as to why a libertarian-minded individual would approve of this proposal.

    1. How does it make sense that punishment for not having coverage for more than X days is to have even more days without coverage? Wow, that is some really harsh punishment that will no doubt have those looking to not purchase coverage run right out and get it.

      1. Because if you get sick and suddenly seek coverage, you will have to wait 6 months. This A: incentivizes maintaining continuous coverage, and B: reduces costs by allowing some of the uninsured sick to die or spontaneously get well (or get well on their own dime) before getting covered.

      2. What I want to know is what is stop someone from simply not getting coverage and then when he gets sick, he simply shows up at an ER? At least with the ObamaRomneyHeritageCare mandate, he has to pay something for not getting coverage (although that mandate is rather toothless). The bottom line is that without repealing EMTALA, this is a crock.

    2. I can’t wait to read 45,000 words as to why a libertarian-minded individual would approve of this proposal.

      45,000? More like 45 characters:

      Because it has a chance to pass & is better than the status quo.

      1. Why is it better? If they can’t ditch Obamacare better to let it die on it’s own and not be the one left holding the bag.

  12. “Instead of a fine for going uncovered, as in Obamacare, the Senate GOP bill now includes a continuous coverage provision: Anyone who goes without coverage for more than 63 days must wait six months before getting coverage again. The goal, as with the mandate, is to create an incentive for health people to buy coverage and maintain it, by penalizing if they don’t.”

    This is far better than the current mandate which forces young healthy people to get insurance they don’t want and which is not in their best interest for the sole purpose of lowering the costs to the rest of the insurance pool.

    1. For the young healthy people it certainly is. Unfortunately young healthy people don’t vote the same way old sick people do.

      If you were a politician interested in keeping your job, would it be better to 1) force young people to buy private insurance to balance the insurance pool, 2) raise taxes on the young and healthy – AKA, workers – to directly fund the healthcare expenditures of the old and sick (single payer, basically), or 3) leave everyone to fend for themselves.

      And remember, old and sick people vote.

    2. Far better? Or just a dumber way of doing the same thing less effectively?

      You have to have the mandate in order for insurance to be affordable to people with pre-existing conditions. It’s the basic framework and logic of the policy.

      1. Right. You have to force people to support others who have made bad decisions in life. Otherwise, those other people might have to face the negative consequences of their bad decisions and we can’t have that.

        1. Cancer is a “bad life decision”?

          1. Not getting health insurance before you get cancer is a “bad life decision”. Getting cancer before you have a chance to get health insurance is extremely rare and can easily be handled with charity. It’s all about choices and values. The vast majority of uninsured people could get it if they wanted. They just either don’t want to work, or want to spend their money on something else.

            1. Not getting health insurance before you get cancer is a “bad life decision”.

              Well the reality is that the ACTUAL decision is:

              Get cancer before you turn 65 and you are screwed and pay for everything yourself and die soon after you get cancer.

              Get cancer after you turn 65 and you get to suck on the public teat and force others to pay everything

              And golly – the chances of making it to 65 without getting diagnosed with cancer are pretty much entirely a function of income. So the higher income get to suck on the public teat – while lecturing the lower income about their ‘bad life decisions’.

              1. chances of making it to 65 without getting diagnosed with cancer are pretty much entirely a function of income

                Either you don’t understand what a “function” is, or you’re willfully conflating correlation with causation.

                There is no coherent mechanistic model to explain your (intentionally or otherwise) implied theory that poverty causes cancer ? although it likely does cause worse outcomes after getting cancer. Meanwhile, lots of carcinogenic choices ? such as cigarette smoking ? are very well correlated poverty, while obviously bearing little to no direct mechanistic causal relationship with it.

                Poverty may lead to a decrease in self-valuation of life, but that is at some fundamental level a choice. And, while it may not be a choice to be predisposed to bad decision-making, when this is the case it reverses the causal direction.

                1. There is no coherent mechanistic model to explain your (intentionally or otherwise) implied theory that poverty causes cancer

                  No simple model. But from Mayo Clinic re the gene mutations that cause (note the word cause) cancers – A number of forces can cause gene mutations, such as smoking, radiation, viruses, cancer-causing chemicals (carcinogens), obesity, hormones, chronic inflammation and a lack of exercise. Every one of those (except maybe hormones) is heavily correlated with income. In concert, those individual factors compound. Further, they are also less likely to have access to the primary care doctor who could say hey this thing or that behavior can cause cancer so let’s fix this early so there is not only increased exposure but longer duration. And yes, once they have cancer, the outcomes are worse too (again an access issue) – even adjusting for the later diagnosis (again an access issue).

                  But hey – I’m sure it’s all just a coinkydink cuz correlation can’t ever actually be causation. That’s like Internet Stats 101. It’s all about the ‘self-valuation of life’ and the freedom to be poor. Doctors serve no real function. They have no medical knowledge that the average poor person doesn’t already have.

          2. If it’s lung cancer it probably was. Not really the point though.

          3. Cancer drugs themselves are, of course, a very limited supply so it’s only natural that Tony won’t get those since he provides no value to society.

            It seems like he’s blissfully unaware of how a government managed system allocates, or doesn’t allocate, care.

            Note how ‘well’ those single-payer systems provided healthcare to people who are old, retired, or infirm. Notably, in how they don’t do those things as much because they’re a drain on the system and have worse odd’s of successful outcomes. I take this to mean that Tony is a heartless utilitarian? Who knew!

            So, now I just gotta ask Tony. Why do you hate old people?

    3. Not just young people – anyone who is not provided with employer/government health coverage – self-employed, small (generally) business owners, part-time workers, etc. As it is now, and even prior to ACA, you are not able to jump on-and-off insurance (other than enrollment periods, without mitigating circumstances).

      It’s surprising at this point in the healthcare debate that essentially no one writing about this issue has a clue how the current system works. Apparently, Suderman believes in a selective “tax” for those without provided coverage.

  13. The problem is the original law is the Republican “free market” approach, as has been explained endlessly, so they’re only left with the option of making it work less efficiently in order to, they hope, satisfy the irrational bloodlust of their moronic base. Seriously, Romneycare covers like 97% of Massachusetts residents and is still functioning well. If Republicans had been less tribal and spent a single minute caring about policy and helping people instead of their neverending ridiculous crusade to be the biggest assholes on the planet, the ACA would be working in their states too.

    All the ACA is is the three-legged stool described in the first couple paragraphs here. It can’t function without all three, and it’s pretty simple to understand. But even simpler is “President McBlackerson’s law is evil because the hedgehog on FOX News said so in my earholes a bunch of times!”

    So I suppose thanks to Republicans for accelerating the conversation toward single-payer faster than Democrats ever could have.

    1. The problem is the original law is the Republican “free market” approach

      Which looks nothing like a free market.

      satisfy the irrational bloodlust of their moronic base

      Someone doesn’t know what bloodlust is…

      Also, it’s really hard to take you seriously when you keep tossing ad homs all over the place. It makes you look a bit unhinged.

      single-payer

      Further obscuring the costs of care will not fix the problem. That kind of manipulation is what drives prices up in every industry throughout all of recorded history.

      1. Nothing screams “free market” like a gigantic layer cake of government mandates.

    2. Why not just join the military and get your single-payer care today, Tony? It’s even managed by Bernie Sanders, so it’s just gotta be the best care around, right? Especially for our heros!

    3. Seriously, Romneycare covers like 97% of Massachusetts residents and is still functioning well.

      Boston Globe: Premiums soar 21 percent for popular health plan

      Mass Live: Higher prices, fewer options as Massachusetts Health Connector begins 2017 enrollment

  14. So Republicans, what is wrong with Direct Primary Care, HSAs and true catastrophic insurance.

    Get employers and the government out of health care and to the extent possible get the government out of healthcare insurance.

    What are you waiting for?

    1. Well, there are even more people calling for single payer or socialized healthcare, and the senate is about 50 votes short of a majority for that. And probably about 98 votes shy of a majority for your plan. That’s what.

      1. If you think even one quarter of the Democrats would vote for a single-payer plan, you’re smoking some good shit. There isn’t a chance in hell, and if you needed proof of that I offer you the following:


        Exhibit A:

        Democrats passed the ACA instead of Single-Payer when they literally could have made it Single-Payer. Without one single Republican vote.

        Yet more proof that Tony is actually a brilliant satirist, since he is almost always 180 degree’s wrong about every single issue he talks about. It’s actually quite unlikely that someone could be so exactly wrong so often without actually trying.

        1. The Democratic party of today is a lot more primed for single payer than they were in 2008. Ben Nelson et al. has left the building. In 2008, Democratic moderates were worried about getting too far away from the center and wouldn’t give their votes to single payer. Now in 2017, any moderates that still exist have a much weaker leg to stand on when they push for a more compromising, bipartisan bill. It’s been proven to the umpteenth time that neither party is interested in working with the other on healthcare, so they’d be better off just going for it.

        2. Wrong, the Democrats of 2009 were timid and, I suppose, thought that ObamaRomneyHeritageCare would be better. Having seen that the mandate has not worked as well as it needed to, they are ready to throw in the towel and go all-in for Medicare-For-All – you know, the type of health care system that Trump said he liked (he mentioned the system like in Scotland & Canada) in front of St. Ronald’s Air Force 1.

    2. They’re waiting for people (in general) to stop wanting a free ride (in general). I wouldn’t hold my breath.

    3. In other words, read the U.S. Constitution, and allow businesses to offer solutions to customers’ problems. The only thing standing in the way is the federal government’s need to control the actions of individual citizens. Piece of cake.

    4. So Republicans, what is wrong with Direct Primary Care, HSAs and true catastrophic insurance…What are you waiting for?

      Campaign contributions. Neither party gives a rat’s ass about actual healthcare. No politician gives a rat’s ass about reducing the long-term cronyism in healthcare – or the % of GDP that is spent on healthcare – since that will reduce the long-term campaign contributions as well.

      Specialists, hospitals, associations, insurance cos paid good money to buy their pols fair and square. And now you want to overturn all that in order to ‘solve a problem’? Gedoudahere.

  15. Re: ” how much of Obamacare’s individual market design Republicans have borrowed for their own bill.”

    Heh. The “Individual Mandate” was thought up in the Heritage Foundation. Neuter Gingrich was for it until he learned, to his horror, that the Kenyan Muslim was adopting it in his plan.

  16. RINO Socialism is just as Socialistic as Democrat Socialism. Power-hungry pols just do not want to relinquish any power gained over the individual.

    Another dagger in the heart of Liberty.

  17. Who don’t these elected “representatives” wake up and smell the coffee? WE DON”T WANT A MANDATE, nor anything else that looks like, functions like, replaces, or substitutes for one.
    What we have been wanting ever since Peligrosi declared “we had to pass the bill to know what’s in it” we have wanted full repeal..

    FedGov have NO AUTHORITY to meddle in medical care, health insurance, or any other such thing. That means THEY CANNOT. The very fact they are is unconstitutional. WHY don’t these dweebs READ that Constitution they swore to uphold, defend, enforce? They all swore an oath to do so. To make such an oath and knowingly fail to uphold it is perjury, an actionable crime that would take every one of them out of office. But here they go…. whatever THEY want, never mind what WE want.

  18. Who don’t these elected “representatives” wake up and smell the coffee? WE DON”T WANT A MANDATE, nor anything else that looks like, functions like, replaces, or substitutes for one.
    What we have been wanting ever since Peligrosi declared “we had to pass the bill to know what’s in it” we have wanted full repeal..

    FedGov have NO AUTHORITY to meddle in medical care, health insurance, or any other such thing. That means THEY CANNOT. The very fact they are is unconstitutional. WHY don’t these dweebs READ that Constitution they swore to uphold, defend, enforce? They all swore an oath to do so. To make such an oath and knowingly fail to uphold it is perjury, an actionable crime that would take every one of them out of office. But here they go…. whatever THEY want, never mind what WE want.

    1. What we have been wanting ever since Peligrosi declared “we had to pass the bill to know what’s in it” we have wanted full repeal..

      A Drumpfista lying about myths he has been force fed through Drumpf’s discard IV

  19. And every single yahoo that gets told “no health care for you” would be become an instant supporter of Medicare-For-All.

  20. I don’t think people should ever be forced to buy insurance on one hand but I know that these programs do not function without the proceeds from payments on the other hand so either I compromise my belief system or I admit that I do not care about health care for people unable to purchase it for themselves from circumstances in their control or not. This is a personal conundrum for me.

    1. Simple solution: get government out of healthcare. If you do not have verifiable means to pay for your healthcare, you do not get it.

      It is the libertarian way. GUARANTEED that it will work. So guaranteed that no one will even think of “but what if it does not work?”

      That is planning.

  21. Nice try, reason.com Republicans posing as libertarians.

    The BCRA is a fully-owned tax cut by the Republicans for their donors. Just be honest enough to call it that. And stop making it “Obamacare-lite.” It is not. 22 million fewer insured is not Obamacare which added to the rolls.

  22. The only rational health care system:
    Health care is not a right, it is a commodity. Period. Every speck of healthcare goods and services is the result of some persons labor. Any time there is a 3rd party payer, there is no incentive for the principles to restrain costs. Indeed, there is every incentive to spend flagrantly.
    These are some easy ways to cut costs, and increase quality of health care. The most important thing is to use free market forces to drive down the cost and drive up the quality of health care itself:

  23. 1. Control the trial lawyers. Limit awards to actual damages with an additional 0-100% of that for ancillary factors unless the health care provider is convicted of a crime
    2. Require all health care providers of goods and services to post their prices
    3. Require all health care providers of goods and services to provide a written estimate
    4. Health care providers of goods and services can set their own prices, but they must charge the same amount to all customers – with a write-down provision only for individuals
    5. Create a before-tax health-care IRA into which you can deposit as much as you want at any time, but not to exceed $6,000 above the actual expenditures per year
    6. Allow any individual to contribute tax-free dollars to anyone else’s HCIRA
    7. Employer health care to be contributions to employees HCIRA
    8. HCIRA used to pay for all medical expenses, including insurance premiums
    9. Any error in billing will require the provider and/or insurer to be cut the bill in half. 2+ errors in billing will negate the bill
    10. HCIRA is heritable
    11. Allow buying any insurance policy from any insurance company anywhere, paid from the HCIRA
    12. Prohibit any health care providers of goods and services from disclosing consumers’ identifying information to the federal government
    13. Allow insurers to write short-term negative-outcome insurance policies
    14. Allow all kinds of medi-share and other such associations
    15. Government assistance/subsidies would be worked through the HCIRA

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