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The Senate GOP's New Health Care Bill Is Just Obamacare, But Less Of It

The draft legislation represents a total failure of Republican policy imagination.

Tom Williams/CQ Roll Call/NewscomTom Williams/CQ Roll Call/NewscomWhen congressional Republicans began drafting health care legislation at the beginning of the year, critics worried that the result would not be the repeal and replace of Obamacare that the GOP had long promised. Instead, they warned, the Republican party was on track to produce something more aptly understood as "Obamacare lite"—a watered down version of the law that is already in place.

Partly this was for procedural reasons: Reconciliation, the budget maneuver which Republicans are relying on to pass a bill in the Senate with a simple majority vote, presents some procedural barriers to full repeal. But those worries also stemmed from long-simmering concerns that, despite having spent seven years campaigning on replacing the health care law, Republicans had developed no substantive health policy goals of their own.

This morning, after weeks of unusual secrecy, the Senate has finally released a draft version of the bill, dubbed the Better Care Reconciliation Act of 2017. In the hours before the bill was made public, details began to leak, and a clear picture of the legislation has emerged. Although Senate Republicans had initially indicated that they would scrap the House bill and start from scratch, the Senate plan looks more than a little like its House counterpart, which kept much of Obamacare's structure in place. But even more tellingly, the Senate plan looks even closer to the health care law that is already on the books.

In other words, it is exactly what critics predicted: a bill that, at least in the near term, retains weakened versions of nearly all of Obamacare's core features while fixing few if any of the problems that Republicans say they want to fix. It is Obamacare lite—the health law that Republicans claim to oppose, but less of it. It represents a total failure of Republican policy imagination.

To understand the Senate plan, it helps to recall Obamacare's underlying framework. The centerpiece of the law was a reform of the individual market, intended to give those who do not get coverage through work or a federal program access to subsidized, regulated coverage. The law created a new federal subsidy, based on income, for lower- and middle-income households to purchase health insurance. It set up federal rules requiring insurers to sell to all comers while limiting their ability to charge based on health history. It mandated that all individuals obtain health coverage or pay a tax penalty. And it erected a system of government-run health insurance exchanges on which consumers could purchase subsidized, regulated individual market coverage.

Those exchanges have never been fully stable as either business or policy propositions. Premiums have marched steadily upwards; last year, the price of a typical plan rose by 22 percent, and early reports show large spikes coming this year as well. The non-profit health insurance organizations that Obamacare funded have mostly shut down. Large, for-profit health insurers, meanwhile, have lost money and either scaled back their participation or dropped out entirely.

Republicans have repeatedly criticized these marketplaces for being expensive and unstable. As Senate Majority Leader Mitch McConnell, who spearheaded the drafting of this bill, likes to say, "Obamacare is collapsing around us."

Yet even more than the House plan, the Senate plan retains the essential structure of Obamacare's individual market reforms. It would likely result in fewer people being covered, and it would not stop the destabilization of the market.

Like the House plan, the Senate plan retains Obamacare's major insurance regulations, including the requirement to cover pre-existing conditions, at the federal level. Unlike the House plan, it does not allow states to apply for a waiver to opt out of those rules. It also eliminates Obamacare's health insurance mandate.

Every state that has attempted this combination of coverage regulations without a mandate has seen a swift meltdown in the individual market. There is every reason to expect that the same would happen under the Senate plan, especially since Obamacare's exchanges were struggling with a too-small, too-sick enrollee pool even with the mandate in place.

The Senate bill attempts to manage this instability by buying off health insurance companies with payments that Republicans previously argued were illegal and should be stopped.

The way it does this is by authorizing additional payments known as cost-sharing reduction (CSR) subsidies to insurers through 2019. It also authorizes the back payment of any CSR subsidies that insurers have not recieved. On this front, it is actually an expansion of Obamacare, and it is a revealing sign of the shallowness of Republican thinking on health care policy.

The Obama administration initially requested congressional authorization to make the CSR payments, which are called for in Obamacare, but not explicitly appropriated. The House did not provide it. The administration then paid them anyway, believing that the exchanges would collapse without them. In response, House Republicans sued, arguing that only Congress has the power to appropriate funds. A federal judge agreed that the Obama administration was violating the constitutional separation of powers. The Trump administration has continued making the payments while threatening to withhold them, adding to the uncertainty for insurers operating in the exchanges.

Now Senate Republicans are proposing to explicitly authorize those payments for the first time. That means they are proposing to explicitly authorize and continue the very policy their House colleagues took the previous administration to court for pursuing. It amounts to an expansion of Obamacare, and while it may reduce uncertainty in some markets, it is unlikely to halt premium increases or fully stabilize the exchanges, which were degrading even before Trump threatened to withhold the payments. Moreover, it is an admission that Republicans do not believe they can meaningfully improve on the Obama administration's implementation of the law.

That same inability to move beyond the core structure of Obamacare is also apparent in the design of the Senate plan's insurance subsidies.

The House version of the AHCA provided subsidies based on age. But the Senate version relies on income-based subsidies, just like Obamacare—but a little less generous. Currently, Obamacare provides subsidies for individual up to 400 percent of the poverty line, or about $98,000 a year for a family of four. Starting in 2020, the Senate bill would ratchet that back to 350 percent of the poverty line, or about $86,000 for the same family. In addition, reports indicate that the subsidies are pegged to lower-cost plans, which means the subsidies will be smaller, and will likely lead to more plans with high deductibles.

Taken on its own terms, this scheme undercuts the GOP's complaints that Obamacare hurts the middle class. In addition to the higher deductibles, it creates a subsidy cliff for middle-class families purchasing health insurance on the individual market. Those who earn slightly too much to qualify for a subsidy would have to pay full price for health coverage that is increasingly expensive.

More generally, it represents a failure to think beyond the confines of the law that is already in place. At a fundamental level, the Senate plan accepts Obamacare's premises about the nature of health insurance and the individual market. It works from the assumption that the only way to make expensive health insurance cheaper is to subsidize it through the federal government. It is a plan that subsidizes, and therefore disguises, unaffordability, rather than attempting to bring down costs directly.

Perhaps the Senate bill's biggest departure from Obamacare is the way it would handle Medicaid. Like the House bill, the Senate plan would slowly roll back Obamacare's Medicaid expansion over a period of years, converting Medicaid into a per-capita system in which federal matching funds are allocated on a per-person basis. It would delay the start of the phase out until 2021, scaling back funding for expansion enrollees a little more each year. In addition, starting in 2025, it would place a stricter cap on the growth of Medicaid spending than the House bill, limiting it to general inflation rather than medical inflation. In the long term, then, the Senate bill's Medicaid cuts would be much deeper.

But even this suggests a resistance to act outside of the parameters already set by Obamacare. Not only is the phase-out slow, but the delays mean that it is susceptible to political reversals. As conservative health policy analyst Chris Jacobs wrote recently, any Medicaid rollback that is delayed until after 2020 essentially requires a Republican president to go into effect. The growth cap, meanwhile, is unlikely to happen unless a Republican wins the White House in 2024. The Medicaid provisions, like much of the bill, appear designed to frustrate nearly everyone. Backers of the expansion oppose the cuts, while critics will worry that they won't happen at all.

The Medicaid provisions—and in particular the altered growth cap—may be best understood as budget gimmicks. On paper, the rollback reduces federal spending, generating estimates of budget savings inside the 10 year window that the Congressional Budget Office uses to score legislation. Those budget savings are necessary for Republicans to use the reconciliation process, but they assume that in the future, Congress will not reverse course. Given that many Republicans from Medicaid expansion states are wary of the rollback, and Democrats universally oppose it, this is far from certain.

Indeed, one of the most striking features of the Senate plan is how many of its major provisions are delayed for years. The CSR subsidies that are now being paid on a month-to-month basis by the Trump administration would continue through 2019. The adjustments to the individual market subsidies would not start until 2020. The Medicaid expansion rollback also would not begin until 2021, and the growth cap would not kick in until 2025.

These delays mean that the current high levels of political uncertainty surrounding Obamacare and the individual market would last for years, through the next two elections and beyond. It is not too hard to imagine some or all of these provisions being delayed further, or even becoming kicked down the road on a semi-permanent basis, as the tweak to physician Medicare reimbursement known as the doc fix was for more than a decade. That, in turn, could result in a health care system that is wracked by permanent instability and uncertainty—one that is always about to change, according to the law, but never or rarely does.

That sort of environment would satisfy almost no one. It would cause headaches for both providers and patients, while making product policy reforms even more difficult, as lawmakers constantly debate changes scheduled to go into effect rather than improvements they would like to see. It would prolong and exacerbate the political squabbling over health care rather than settle it.

For Republicans, this might be the notable failure to think beyond the terms set by Obamacare. It means that Senate bill not only won't be Obamacare repeal, it might not even be Obamacare lite. Instead, it might be Obamacare lite—later. And later could easily turn out to be never.

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  • mashed potatoes||

    i hate to support the idea that they are capable of being strategic and act intelligently.. but i get the sneaking suspicion this is designed to fail.. remove it from the agenda to something less energizing to democrats before 2018..

  • Tony||

    Mitch McConnell may be an amoral cynical nihilist, but he's not stupid.

  • Eman||

    Not mutually exclusive!

  • Michael Hihn||

    BINGO! Republicans -- like libertarians -- pissed and moaned for all these years ... but NEVER had anything,
    So they'll tell their base that they tried their best. Trump will spew more bullshit. And Rand Paul will continue shitting on will of the people and consent of the governed, while opposing the OUTCOMES of a free market, like his dad, to excite the goobers..

  • buybuydandavis||

    Nope. They just don't have the Senate votes to overturn Obamacare. They don't have the votes for closure. Hence reconciliation. Hence limited changes.

    Maybe they couldn't get together a bill on their own. Maybe not. All academic. They don't have the votes now.

  • Michael Hihn||

    Good answer. To a different mater. I assume the website placed yours under the wrong comment, since it has nothing to do with my comment.

    They had WAY fewer votes over the previous seven years ... which would also be a lame excuse for never having a credible alternative. And .... having a clue on so critical an issue, would have likely given them more seats,

    It would also help if Trump wasn't such a divisive asshole. Even Obamacare had a bipartisan proposal -- but it was Republicans who rejected it -- forcing Obama to work with his extreme left. Obama seems to have copied Kennedy's tax cuts -- where JFK ignored his own far left to work with Republicans, giving him a lot more votes, a law with broader voter appeal ... that TOTALLY pissed off his own far-left in Congress, and the AFL-CIO. And, of course, Obama won his nomination, and the Presidency, as a centrist on healthcare.

    If you followed the deal-brokering for Obamacare, the Rockefeller Democrats (far-left) were added LAST.

    And there's a LOT more than votes at stake. Only 16% of all voters support the AHCA, and fewer than 25% of Republicans. Obamacare has SOARED in popularity, largely because they saw it was the best alternative.

  • JFree||

    They have succeeded then. This is the Better Care Reconciliation Act. Presumably the 'Reconciliation' part will be reconciled out of the consolidated bill. So it will ultimately become the Better Care Act. How can you oppose that? Are you in favor of Worse Care?

    The R's have managed a slam dunk here. Short. Pithy. Descriptive. Unopposable by everyone except AlQaeda (and of course libertarians from Somalia).

  • Tionico||

    what specific varietal are you smoking these days?

  • JFree||

    Why do you hate America?

  • Michael Hihn||

    Why do you hate libertarians ,... while admitting you know nothing about us?

  • buybuydandavis||

    Better and actual is better than utopian and unreal.

  • Rich||

    Reconciliation, the budget maneuver which Republicans are relying on to pass a bill in the Senate with a simple majority vote, presents some procedural barriers to full repeal.

    That's why they get paid the big bucks.

  • Ken Shultz||

    The Republican plan fundamentally destroys ObamaCare.

    1) It kills the ObamaCare Medicaid expansion.

    ObamaCare can be correctly characterized as a Medicaid expansion with various rules (including the individual mandate) put in place to hopefully protect the industry from the negative consequences of expanding Medicaid.

    Moving people from the ObamaCare Medicaid expansion onto private insurance by way of subsidies is exactly like moving kids from failing public schools into private schools with vouchers. This is not merely the means to destroy ObamaCare and the ObamaCare Medicaid expansion--this is the road map for getting rid of the rest of Medicaid, too.

    2) It kills the individual mandate.

    The individual mandate is morally unconscionable from a libertarian perspective.

    And, no, letting private insurance companies charge a significant free to those who stopped paying their insurance premiums if they want to get back on an insurance plan isn't like ObamaCare siccing the IRS on those who don't buy broccoli or health insurance at all.

    For instance, under the Republican plan, there is not penalty for not buying insurance.

  • Hugh Akston||

    It's kind of annoying to be sure, but I think we should feel at least a little flattered that Trump's propaganda strategists decided to beta test their Ken Schutlz spambot here at H&R.

  • Ken Shultz||

    Your ad hominems aren't really annoying; they're just pathetic.

    Are you saying that moving people from Medicaid to private insurance with subsidies isn't like moving kids from public school to private school with vouchers?

    Are you saying that health insurance companies charging a fee to those want back on a plan after skipping out on their premium payments is exactly like siccing the IRS on people for not buying insurance?

    No, you're not saying that--you're just calling me names.

    That's pathetic.

  • Michael Hihn||

    Are you saying that moving people from Medicaid to private insurance with subsidies

    (laughing) That never happened.

    Are you saying that health insurance companies charging a fee to those want back on a plan after skipping out on their premium payments is exactly like siccing the IRS on people for not buying insurance?

    Pay attention.
    1) The mandate was demanded by heath insurers, in return for guaranteed issue, to offset the risks of covering sick people, and make sure people didn't wait until they were sick to by coverage.
    2) Repealing the mandate, but keeping guaranteed issue, GUARANTEES an even worse death spiral! Do the math. REPUBLICANS WOULD GUARANTEE YOUR RIGHT TO BUY FIRE INSURANCE ON A BURNING HOUSE.

    We also lose because our own establishment is totally clueless onthe issues. Suderman has no clue what the Cost-Reduction Subsidies do .,.. a necessary first step toward genuine free-market reforms (which the libertarians establishment actually OPPOSES!)

    you're just calling me names.

    Yes, he did. I explained WHY you remain a GOP trolling spambot

  • buybuydandavis||

    Your ad hominems aren't really annoying; they're just pathetic.

    And predictable.

    The more Progressitarians adopt Progressive values and policies, they more they adopt their tactics.

  • Michael Hihn||

    The more Progressitarians adopt Progressive values and policies, they more they adopt their tactics.

    It's actually tribalism, and applies to every single tribe in America.
    Your comment is tribal .,.. since he's actually a rather dogmatic conservative.

    Your way, it's not just Progressitarians, Conservatarians are the same. As proof, look how extreme social conservatism has evolved Ron Pauil into a raging fascist bigot -- lying about the constitution, ridiculing balance of power, checks and balances, three co-equal and unalienable rights. He even brags of authoring a bill that would have forbidden SCOTUS to even consider any challenges to DOMA -- making gays the first people denied the protection of fundamental rights since slavery. He's now a major hero to the alt-right ... and google him with the power-asshole lex Jones and Infowars.

    His 10th Amendment bullshit enables all the very worst bigots in America. Worse than even George Wallace, Orval Faubus and their ilk.

  • chemjeff||

    "1) It kills the ObamaCare Medicaid expansion."

    It doesn't even do that, Ken. They are using the same typical gimmicks like "balance the budget with spending cuts later (meaning: never)".

  • Ken Shultz||

    It does do that.

    If you're saying they may undo x, y, and z in some future congress so we shouldn't support doing x, y, or z today, that doesn't make any sense to me.

    The bill cuts back eligibility for Medicaid that was expanded under ObamaCare.

    I can both support doing that today and oppose undoing it tomorrow.

    The threat of future congresses undoing legislation is always present.

  • chemjeff||

    No, I'm saying that they should begin by phasing out the subsidies the day after the bill is signed.

    The Republicans are LYING to you, Ken. They have no real intention of phasing out the subsidies at all. They are only using them as a tool for electoral purposes (gee, I wonder why the phase-out starts in 2021, right after the presidential election?? Coincidence???)

  • Ken Shultz||

    "No, I'm saying that they should begin by phasing out the subsidies the day after the bill is signed."

    You seem to be confused about what's happening here.

    Subsidies are the replacement for Medicaid eligibility.

    You move people from Medicaid to private insurance through subsidies like you move students from public schools to private schools with vouchers.

    This is not a libertarian congress. No one is going to propose cutting Medicaid and letting those people twist in the wind, and no one is going to vote for that kind of plan. It has no chance of passing.

    We're talking about a bill that cuts Medicaid that does have a chance of passing. It already passed the House. It's within a vote or two of passing in the Senate.

  • chemjeff||

    Okay, yes. I read it a little bit more carefully this time. But the overall point still remains. They are not doing anything to the Medicaid eligibility until after the election.

    It is a pretend vote to cut Medicaid only if you promise to vote Republican in the next election, and after that, then wellllll maaaaaaaybe.

  • mortiscrum||

    It also completely acquiesces to the CSR subsidies. This was surprising to me; I thought the Republicans were pretty well dug in on that point.

    Suderman is entirely correct when he says "More generally, it represents a failure to think beyond the confines of the law that is already in place." I've defended the ACA several times here, but I was at least hoping that the Republicans were going to put forth an actual viable alternative that isn't single-payer. Instead, they've basically just made a version of the ACA that's notably worse in several ways and much more likely to collapse and allow a clear lane for Medicaid/Medicare for all.

  • Michael Hihn||

    It also completely acquiesces to the CSR subsidies.

    1) Read it again.
    2) Suderman seems to have no idea what those subsidies do. Do you? Please be specific,

  • mortiscrum||

    Why, so you can pedantically pick apart anything I said, followed by belittlement? No thanks. You are one of the most unpleasant people that frequents this comment section. If you're actually interested in dialogue, you aught to not build a reputation as a complete fruitcake.

  • Michael Hihn||

    Why, so you can pedantically pick apart anything I said,

    Since YOU asked ...
    No. It's because you're wrong!!. And now you THINK you can intimidate me (lol)

    You are one of the most unpleasant people that frequents this comment section.

    Precious snowflake was triggered by "Read it again." (sob)

    If you're actually interested in dialogue, you aught to not build a reputation as a complete fruitcake.

    Shoulda read it again (smirk) I'll go slowly.

    Suderman
    The way it does this is by authorizing additional payments known as cost-sharing reduction (CSR) subsidies to insurers through 2019

    Bully
    It also completely acquiesces to the CSR subsidies.

    Or did THIS trigger you?
    "Suderman seems to have no idea what those subsidies do. Do you? Please be specific,"

    NO ANSWER! INTIMIDATION. PERSONAL ATTACKS. NAME-CALLING.

    ***DO YOU KNOW WHAT THE CSR SUBSIDIES ARE? PLEASE BE SPECIFIC.

    (My tone is in defense of aggression by a-thug, a rather childish one)

  • mortiscrum||

    Like clockwork....

  • Michael Hihn||

    Stop whnig, snowflake.

  • Michael Hihn||

    Correction: whining

  • Ken Shultz||

    "They are not doing anything to the Medicaid eligibility until after the election."

    Are you over the age of 14?

  • Michael Hihn||

    Are you over the age of 14?

    Ummm,.

    "The Medicaid expansion rollback also would not begin until 2021, and the growth cap would not kick in until 2025.

    That's after the next Presidential election ... and inauguration!

  • buybuydandavis||

    We're talking about a bill that cuts Medicaid that does have a chance of passing. It already passed the House. It's within a vote or two of passing in the Senate.

    Passing legislation to improve the situation? Who cares about that?

    Muh Principles!

  • ||

    It lets them charge a 30% premium. Treating serious injuries can cost tens of thousands of dollars, treating serious illnesses can cost hundreds of thousands of dollars. If I can buy car insurance after I crash the car, 30% in additional cost isn't going to stop me, or persuade me to buy in beforehand like I'm supposed to.

    This bill fixes nothing, and is worse than Obamacare in every single way. The worst of it remains intact and even more unpaid for.

  • Ken Shultz||

    Saying that increases in prices don't impact consumer behavior is a very strange thing to read on a libertarian website.

    Right now there is no penalty for skipping payments and then suddenly coming back onto the plan once you're sick and charging people a fee to help curb that kind of behavior is an improvement.

    However, that wasn't the comparison I was making.

    Suderman has suggested in the past that the Republican plan doesn't really get rid of the individual mandate because it lets insurers charge a premium for jumping back on a plan after skipping payments--which Suderman was calling a penalty for not buying insurance.

    My argument was that letting insurers charge a fee to let you back on a plan after skipping payments isn't like siccing the IRS on you for not buying insurance.

    You seem to be suggesting that the fee for jumping off and on insurance by skipping premium payments should be higher--or that the insurers shouldn't be required to take you back. I think I agree with that.

    But that wasn't the comparison I was making. I was comparing the individual mandate to being free to not but insurance without the IRS coming after you.

  • Michael Hihn||

    Saying that increases in prices don't impact consumer behavior is a very strange thing to read on a libertarian website.

    Shultz-Troll screws up again.
    What he SAID was -- a 30% higher premium is STILL cheaper than "treating serious illnesses can cost hundreds of thousands of dollars."

    However, that wasn't the comparison I was making.

    You blew that, too.

    My argument was that letting insurers charge a fee to let you back on a plan after skipping payments isn't like siccing the IRS on you for not buying insurance.

    WHOOOOSH (over your head)
    You looked at gubmint and not the markets, then you whine about consumers when called out for your screw up. And even misread the challenge!

    You seem to be suggesting that the fee for jumping off and on insurance by skipping premium payments should be higher--or that the insurers shouldn't be required to take you back. I think I agree with that.

    Then you admit the GOP fucked up.

  • swampwiz||

    It's not exactly just a Medicaid expansion, but also a negative tax for folks at low income. What Republican yahoos don't understand is that this negative tax would be so high for folks under 138% of poverty that the LOW-COST Medicaid coverage is cheaper.

  • chemjeff||

    Both left and right now agree with the basic premise of government-run health care.

    Single payer is now just a matter of time.

    Sigh. It was fun while it lasted...

  • $park¥ leftist poser||

    Both left and right now agree with the basic premise of government-run health care insurance.

    Fixed it.

  • Dillinger||

    cross the "left and right" part out too...same team.

  • Robert||

    Actually it is pretty much basic agreement on this worldwide. Overwhelming majorities everywhere think that if a society is not very poor, that everybody in it should be made to take care of sick people.

  • Michael Hihn||

    everywhere think that if a society is not very poor, that everybody in it should be made to take care of sick people.

    All the more shame on us -- our libertarian establishment -- for allowing it. Now ... but NOT in the 70s and 80s.

    Out our society did exactly that .. for everyone ... far more successfully ... before BOTH health insurance companies AND government. .,.. from BOTH big parties,

    One party sucks up to Big Insurance, the other to Big Government. And the libertarian establishment (Cato/Mercatus/Reason.com) sucks up to the Big Insurance tribe. Lady Liberty is under the worst attack of her existence .. and totally undefended.

    Progressives are kicking our ass in public opinion, on EVERY major issue. Thank goodness they suck at governing as bad as today's conservatives. Americans are MORE than ready for even radical change ... but Trump was the only one CLAIMING any at all.

  • Jerryskids||

    If the Democrats proposed we all jump off a 500-foot cliff this afternoon, the GOP would be right there with a counter-proposal that we jump off a 400-foot cliff tomorrow morning. 5 seconds after Obamacare passed, the GOP went from talking about repealing it to talking about fixing it. Now that it's crashing and burning, they can't wait to shove the Democrats out of the way so they can get behind the wheel just in time to take credit for the explosion.

  • Ken Shultz||

    Except that eliminating the Medicaid expansion and getting rid of the individual mandate isn't anything at all like jumping off a cliff.

    It's more like putting out a fire.

  • WakaWaka||

    Eliminating the individual mandate is great, but Medicaid expansion is not being eliminated- it is being phased in. Which means it will never happen

  • Calidissident||

    Let's also not forget that their replacement for the mandate (to attempt to maintain a stable market) is payoffs to insurance companies.

  • paranoid android||

    It's absolutely laden with corporate welfare and market intervention on every page, but if you ignore ALL of that and focus exclusively on this one tiny corner that Ken likes, it's a hell of a great bill!

  • Ken Shultz||

    I don't see this as the last healthcare bill we'll ever have.

    That being said, I'd support the bill if it were only getting rid of the individual mandate, which is morally unconscionable.

    We can talk about the merits of slavery, internment camps, torture, etc., but in the end, I oppose those things on moral grounds that have little or nothing to do with their utility.

    Because the bill also eliminates the Medicaid expansion, I support the bill enthusiastically.]

    I didn't say it was all libertarian all the way through, but the main opposition to the bill within the Republican party is because the bill is so libertarian. It's as libertarian a bill as can be reasonably expected from a non-libertarian Congress. If it were any more libertarian, it wouldn't have any chance of passing.

    And it's not as if the status quo represented some kind of libertarian default option. We make it as libertarian as the present Congress will allow, and then we keep fighting for something even better.

    If I'm a nerd and I get to take a Sports Illustrated swimsuit model to the prom, I don't refuse to go and just stay home because the one I got wasn't Gigi Habib.

  • BYODB||


    I don't see this as the last healthcare bill we'll ever have.


    You're right. There will be a full nationalization bill, and it will pass. This is an inevitable result Ken. I know you don't want to hear that, or believe it, but the people have spoken. They want something for nothing, and their chicks for free.


    Why would a politician vote themselves out of office by not giving away the free bennies their constituants are clamoring for? Just look at how the entire public debate is framed, and realize that there is only one outcome that's possible barring major market failure; nationalization. It will happen.


    The best we can hope for is that the experiment isn't long lived given it's massive price tag, but the government is pretty creative with things like excise taxes. After all, everyone knows that an excise tax has no effect upon the price of a thing so when the price goes up it must be because the corporation is greedy. Duh!

  • Ken Shultz||

    "You're right. There will be a full nationalization bill, and it will pass. This is an inevitable result Ken."

    There's this thing called a slippery slope. It isn't a real thing. It's a logical fallacy.

    Enacting the means by which we can avoid nationalization is not the path to nationalization.

    Moving people off of Medicaid and onto private plans is not the path to nationalization.

    Eliminating the individual mandate is not the path to nationalization.

    Markets don't need a lot of room to be better than nationalization, but this bill gives us even more room for markets to function--and that should be supported.

    I don't believe there has ever been a time when Medicaid eligibility was cut back. If we can get that through a non-libertarian Congress, then the fat lady hasn't sung yet.

  • BYODB||

    It's not a slippery slope argument Ken, it's a preferred policy position of the Democrat party and their political base. Unless you think that the Democrats are going to implode and/or lose all political power, I'm not sure how you can't see the gradual march towards nationalized healthcare.

    If one of our two major political parties weren't actively championing nationalized healthcare as their preferred policy position than maybe then I would be making a slippery slope argument. The very fact that the only other candidate for the Democrat party for President of the United States was an actual socialist who is absolutely for nationalized healthcare maybe you would have a point.

  • BYODB||

    Terrible writing on my part.

    Essentially when a major candidate for President of the United States espouses things like free college tuition and single-payer healthcare and they manage to almost beat the other candidate, who had the political machinery of their party actively suppressing them, then maybe it's something a little more than a slippery slope argument.

    It isn't a slippery slope, it's an active movement towards a goal. There's a difference.

  • Migrant Log Chipper||

    This ^^^^VA level services for all. I'll be laughing at my retired gov worker, pro single payer friends when they lose their decent insurance bennies and choices and get an NHS level clusterfuck in exchange.

  • paranoid android||

    I didn't say it was all libertarian all the way through, but the main opposition to the bill within the Republican party is because the bill is so libertarian.

    So if they pass this thing and the problems that they claim they are aiming to fix--rising premiums, carriers fleeing the market, etc, etc--continue as they are and get worse, what do you think will happen?

    Republicans and Democrats will join hands and say "We let the free market zealots try their way and it failed; single-payer it is". There's no chance of a better law further down the line because Republicans aren't interested in free-market or libertarian solutions, they're interested in grandstanding and pandering to their base.

    Those who prefer our kind of solutions should not let their own reputations be tarnished by supporting what by all appearances is a rearranging of deck chairs on the Titanic.

    And that's before we get into the hypocrisy of Republicans putting this together in backroom meetings with lobbyists after years of criticizing the Democrats on exactly those grounds. The whole fuckin' thing stinks.

  • Ken Shultz||

    "So if they pass this thing and the problems that they claim they are aiming to fix--rising premiums, carriers fleeing the market, etc, etc--continue as they are and get worse, what do you think will happen?"

    The problems we're having are a result of socialist policies.

    More capitalist polices are the solution to those problems.

    As the policies become more capitalist, I expect those problems to get better.

    I remain steadfast that Medicare and Medicaid are ultimate source of our problems.

    Come to terms with this, and there's no reason to think that killing the Medicaid expansion won't improve our problems.

    Get your head around this chart:

    http://tinyurl.com/lcayz2f

    See what is says. Understand what it means.

    This is one of the few bills I've seen that actually addresses the cause of our problems directly.

  • Calidissident||

    Depending on how the Medicaid "cuts" work, it's possible this bill would worsen that problem. If they're using per capita funding, the reimbursement rates will get worse if medical inflation exceeds general inflation (which it usually has in recent decades). If the number of people on Medicaid gets rolled back that helps, but even under the most generous of estimates you're looking at tens of millions of people still on Medicaid, so that's still a major problem for the system.

    Of course, this is generously assuming the cuts actually happen at all, which is pretty much dependent on the Republicans winning the 2020 and 2024 elections.

  • Ken Shultz||

    "Depending on how the Medicaid "cuts" work, it's possible this bill would worsen that problem."

    Wrong.

    What the chart shows is that because Medicaid and Medicare only pay for a portion of the cost of care, providers gouge insurance companies to make up for the difference.

    The purpose of of the individual mandate was to help insurers deal with getting gouged as ObamaCare expanded Medicaid.

    The more Medicaid patients there are, the more money providers lose taking care of Medicaid patients and the more they need to gouge insurers to make up for their losses.

    Reimbursement is tied to codes--diagnoses and procedure codes. It is an important fact to understand that when you take all the procedure and diagnosis codes and pay all of the money Medicaid pays out in a year, it is not enough to cover the cost of providing for all those Medicaid patients.

    TANSTAAFL

    The reason average insurers have to pay out 150% of the cost of care for their customers is because they have to make up for all the money providers lose taking care of Medicare and Medicaid patients.

    Hospitals in low income areas that can't find enough private insurance patients to gouge to make up for Medicaid losses go bust. In recent years, more than a dozen have done so in New York City alone--and it's because of Medicaid.

    Look at the chart again. Get your head around it, or you have no idea what the real problem is. This bill directly addresses the cause of the problem--which is a rare thing.

  • kyleh||

    Cost-shifting is the outcome of competition between payers in contract negotiations with providers. See for example how Amazon affected shipping prices for independent retailers after negotiating their own discount with shipping companies. If you don't like cost-shifting, then maybe *all-payer rate setting* is what you want. Don't hate Medicare and Medicaid just because they have big negotiating power in the market.

  • Michael Hihn||

    kyleh|6.23.17 @ 3:00PM
    Cost-shifting is the outcome of competition between payers in contract negotiations with providers

    In health care it means how private insurers are forced to subsidize Medicare and Medicaid -- as THEIR costs are "shifted" to private payers,

    Actual example: The esteemed Mayo Clinic began refusing Medicare as full payment in 2010, for primary care, citing losses of $840 million. Their patients must now pay an extra "copay" to Mayo,. on top of their Medicare copays and deductibles ... plus patients must file their own claims with Medicare.

    This one's easy. They cannot report a loss unless they actually write the checks. So where did they get the $840 million from? Who did they overcharge? Their only other major source of revenue is private insurance. Do the math. Private insurance paid Mayo $840 million to treat Medicare patients!

    If we extrapolate that to the entire Medicare population, then private insurance subsidizes About $125 BILLION of Medicare treatment, probably more since even Obama praises Mayoi as one of the most efficient providers. This is ON TOP OF 42% of all Medicare actual spending subsidized from income taxes (not the Trust Fund) ... roughly $450 billion in subsidies to Medicare

  • kyleh||

    I understand your point, but even if public payers are out of the picture, there will still be cost shifting. Private insurers subsidize *each other*, because companies with bigger membership can negotiate lower adjusted rates, and smaller companies will make it up. The bigger a company's medical membership, the lower the rate it can get away with. Medicare and Medicaid each have greater enrollment than any private insurance company in the US, so of course costs are shifted to private insurance.

    I understand this situation puts people in private insurance under more pain, but that's the market in action. All this cost-shifting is literally (of course) just shifting costs around and does nothing about how overall US healthcare expenses per person are 2x other typical advanced nations.

  • Michael Hihn||

    Part 1 of 3

    even if public payers are out of the picture, there will still be cost shifting.

    Which is why I hate the term as tribal jargon.

    Private insurers subsidize *each other*, because companies with bigger membership can negotiate lower adjusted rates, and smaller companies will make it up

    That's not a subsidy, and it's dead wrong. Premiums are based on the risk of each group. Many smaller employers pay a lot less than GM or Microsoft, simply because they have much younger employees.

    PLEASE don't suggest that a mom and pop grocery store subsidizes Wal-Mart!

    The bigger a company's medical membership, the lower the rate it can get away

    I've already explained why that is wrong,.

    with. Medicare and Medicaid each have greater enrollment than any private insurance company in the US, so of course costs are shifted to private insurance.

    Are you serious? You don't know that Medicare INTENTIONALLY underpays providers? Never heard of DocFix? Medicaid pays even worse, which is why Medicaid eligibles have the highest uninsured percentage in America .. so people with a "guaranteed right" to health care don't have it, so more die uninsured. Many inner cities have NO DOCTORS AT ALL.. If there aren't enough private insured to recover their losses by over-charging, they can't exist on as little as $17 per visit. People die, uninsured in your paradise,

  • Michael Hihn||

    Part 2

    All this cost-shifting is literally (of course) just shifting costs around and does nothing about how overall US healthcare expenses per person are 2x other typical advanced nations.

    No .. but three other facts demolish THAT fallacy,

    1) We spend more money per capita on public healthcare alone .. for about 40% of our population ... than TOTAL per capita healthcare spending in Sweden, the U.K., Australia, New Zealand, and Japan. Proof on page 3 So if if every private insurer disappeared, AND all their customers never needed more care ,.. we'd STILL spend more than those five countries!! ... PLUS the half-trillion in subsidies from the private sector would disappear!! Here's why:

    2) We're the ONLY country that spends $250,000 or more for sic months of life or less, HALF our entire healthcare spending is spend in the last two years of somebody's life .. as first announced by Hillary Clinton for HillaryCare. THAT explains BOTH – our highest healthcare costs AND that Medicare is the cause. NOT because it's gummint, but because of how we treat our seniors.

    3) POLITICAL healthcare means betting your life, literally, that when politicians face tight budgets they will ALWAYS increase your taxes and NEVER cut your benefits. SERIOUSLY?

  • Michael Hihn||

    Part 3

    They let people die as PROVEN in Canada and TOTAL BARBARITY in England

    In Canada, their system was ruled an unconstitutional threat to human life, citing all the Canadians dying on waiting lists of a year of more. "access to a waiting list is not access to health care.". (That link is to a GOVERNMENT network)

    In a related action, Provincial governments forced the central government to restore our GDP equivalent of a half trillion dollars .. to reduce waiting times and ADD costly diagnostic testing we've had since the 50s.

    Canadian women over 40 are 35% LESS likely to have a recent mammogram. Nobody knows how many of those women die of breast cancers that was NEVER DETECTED.

    In England, 14 hospitals were condemned for barbaric levels of care. THOUSANDS of patients died "needlesly" - after being wheeled into rooms and totally abandoned, Many were found dead in their own excrement. All caused by severe understaffing of nurses, caused by .... spending cuts instead of increasing taxes!

    That's why England's death rate is 45% higher than ours IN HOSPITALS.

    But you, somehow, want Americans to double their own taxes ... and switch to BARBARITY?

  • kyleh||

    I don't know why you brought up premiums - I thought we were talking about insurance companies and the adjusted rates they negotiate with healthcare providers. Sorry if I wasn't clear. Of course premiums are set based on actuarial calculations of expected total healthcare costs (risk).

    (Cont...)

  • kyleh||

    ...

    Anyway, the cost shifting/subsidy phenomenon has a name - the "waterbed effect" - and it occurs in markets with all private entities as well as in healthcare with private insurance companies and public entities. The point is that after accounting for buyer differences in economies of scale, logistics, and any other real effects that lower the seller's cost to sell to that buyer, there is also negotiation which depends on buyer power. So Amazon gets an extra low rate from FedEx not just due to superior logistics and economy of scale, which save FedEx money, but also because Amazon is a big, important customer. That last piece - their buyer power - gives them an upper hand in negotiating lower rates which are not entirely due to efficiency of doing business with Amazon. Smaller customers of FedEx without Amazon's buyer power then pick up the slack with higher rates. In the analogy, FedEx = hospital, Amazon = Medicaid, small FedEx customer = private insurance. That's my best effort to explain it - sorry if you don't buy it.

    I did walk into that demolishing, forgetting about the elderly on Medicare and end-of-life care. Reflecting on end of life also makes me want to get off comment sections.

    Thank you for your other comments and link to the CBC piece. I favor single payer (certainly not U.K.-style nationalized healthcare) but I'll keep an open mind.

  • ||

    More capitalist polices are the solution to those problems.

    Free Markets are the solution. Capitalism we have plenty of, but we're heading more toward the Chinese Communist Party version of capitalism and away from free markets.

  • mortiscrum||

    RE: Free Markets

    An important distinction to make. Effectively, no one in the country is interested in free markets - least of all the existing big businesses.

  • ||

    Effectively, no one in the country is interested in free markets - least of all the existing big businesses.

    Preaching to the choir, man.

  • Robert||

    So if they pass this thing and the problems that they claim they are aiming to fix--rising premiums, carriers fleeing the market, etc, etc--continue as they are and get worse, what do you think will happen?


    Politicians will say—not in so many words, but the way politics works—that if you, the voters, will let us, we'll do away with the dysfunction, rather than getting deeper into the Big Muddy.

    What do you think will happen if, in response to increasing legaliz'n of marijuana, more people use it? Will the rxn be, we tried loosening the law but people misbehaved so we have to tighten it again? Or will more people see there's no problem with use per se, and support getting rid of more dysfunction in the laws?

    I've seen so much good come out of gradual change, it'd be silly to be against it because it's gradual. And slowing down a rush toward badness is a gradual anti-bad change, probably the necessary 1st step to actually moving away from badness.

  • Calidissident||

    Opposition to the bill has come from both the moderate and conservative/libertarian wing. Rand Paul and Mike Lee are probably the most likely senators to vote against it.

  • Ken Shultz||

    "Opposition to the bill has come from both the moderate and conservative/libertarian wing. Rand Paul and Mike Lee are probably the most likely senators to vote against it."

  • Ken Shultz||

    I have no idea why it cut off most of my comment.

    Short version:

    There are four libertarians/fiscal conservatives getting the headlines because they aren't getting what they want.

    If they got what they wanted, more than a dozen moderates wouldn't support it.

    Take a look at who voted against the AHCA:

    http://tinyurl.com/ybe73jtc

    17 of the twenty were from moderate or swing states. It's the same thing in the Senate.

    Meanwhile, neither Cruz nor Rand Paul are about to take the blame for killing the repeal of ObamaCare--not if they want to turn around and run for president in the Republicans primaries.

    They're mostly just making suggestions of what needs to change in order to get their support.

    The real opposition is from moderates. They don't like cutting Medicaid.

  • Robert||

    ^^^^
    That. Even though I've no idea who Gigi Habib is.

  • buybuydandavis||

    I don't see this as the last healthcare bill we'll ever have.

    One Bill to Rule them All!

    If I don't get every last thing I want NOW NOW NOW, I'm not buying in!

    Muh Principles!

  • Michael Hihn||

    Let's also not forget that their replacement for the mandate (to attempt to maintain a stable market) is payoffs to insurance companies.

    GOP propaganda ... if you mean the CSRs (Cost Sharing Reductions) .... (you've excluded the mandate)

    CSRs' address the same dumbfuck ideas promoted by Cato and virtually all of the right.
    The TOTALLY fraudulent notion of large co-pays and deductibles -- because they have no clue how to reduce PROVIDER costs, (Hold on!)

    Consider: a $5,000 deductible per person, not high by today's standards.
    SOUNDS good, because most folks would not spend that much all year, OR could simply refuse to.

    Until they get cancer.

    If YOU get diagnosed with cancer tomorrow .,.. have YOU got $5,000? Does a low-wage worker? have you been suckered?

    Catastrophic insurance is a great concept ... based on catastrophic AFFLICTIONS not dollars!

    The hustle works like this, In HSA's, a $5,000 deductible is offset by cash from your employer. In a Medicaid or Exchange plan, the $5,000 deductible is offset by NOTHING. Nothing at all.
    And THAT is how totally bankrupt are today's fiscal conservatives.

    Poor people buy the highest deductible plans .. all they can afford ... the same folks who CANNOT PAY that deductible! Not just Obamacare - also Cato, with different trickery to hide the same scam.
    Ours IS one of the Political Elites.

  • Ken Shultz||

    "It is being phased in. Which means it will never happen"

    If that were true, we wouldn't have ObamaCare.

    I assure you, there are lots of things that have happened despite being phased in.

  • Calidissident||

    Come on Ken, you should know it's always a lot easier to phase in a government program than phase it out.

  • Ken Shultz||

    And if the only way to get something libertarian passed is to phase it in, then we should do that.

  • chemjeff||

    And Paul Ryan's budget from 2011 really did cut spending over 10 years!

  • Ken Shultz||

    Are you trying to suggest that Trump will shut down the government over a Republican spending bill like Obama did?

    Are you saying that Ryan will shut down the government over Trump refusing to fund Medicaid?

    I don't get it.

  • chemjeff||

    I'm saying that Paul Ryan balanced his budget in 2011 with tricks and gimmicks that no one ever believed would happen, but the tricks and gimmicks allowed him to say that his plan was "fiscally responsible". It is the same thing here. The Republicans are using gimmicks and tricks to allow themselves the illusion of being able to say that they are "reforming Medicaid" but in reality they are just kicking the can down the road and promising to maybe do something about it only if you promise to re-elect them in 2020.

  • Michael Hihn||

    Rand Paul did the same bullshit ... for a different set of suckers.

    From a politician, a balanced budget is a bunch of numbers on a spreadsheet. You want to see mine?

    Give me 10 years of detailed budget forecasts, a $10 calculator, 48 hours, and how soon you want me to balance the budget. Just that easy, and you know it. Libertarians are bamboozled and flim-flammed by just as much tribal bullshit as progressives and extreme social conservatives. BUT ITS OUR TRIBE.
    And Hillary had a private server,

  • Domestic Dissident||

    This is one of the favorite schticks of the lying professional fake libertarians who make up almost all of Reason now. Criticize the republicans when they expand programs like Medicare and Medicaid (completely 100% deserved), and then also criticize them on those (rare) occasions when they actually vote to cut programs like Medicare and Medicaid.

    MacAdoodle, who is one of the biggest lying fakers working here, has changed his attack line and general story on this issue more times than Joliet Jake Blues changed his story when the "Mystery Woman" finally caught up to him.

  • Calidissident||

    I'm not sure if a guy who has Donald Trump's dick perpetually lodged in his throat has room to call anyone else a fake libertarian.

  • chemjeff||

  • Domestic Dissident||

    I'm not sure if anyone who loves the status quo as much as you do deserves to call himself a "dissident".

    Your screen name would be much more accurate if it were "Calistatusquo".

  • Calidissident||

    Yeah, a real dissident spends his days carrying water for the incumbent president.

  • Michael Hihn||

    This is one of the favorite schticks of the lying professional fake libertarians who make up almost all of Reason now.

    (lol)

    Criticize the republicans when they expand programs like Medicare and Medicaid … and then also criticize them on those (rare) occasions when they actually vote to cut programs like Medicare and Medicaid.

    1) When and where?
    2) A favorite schtick of anti-gubmint goobers is to REPEAL MEDICAID ... proving they know nothing about free markets.
    3) When we HAD free markets, EVERYONE seeking care got it. paid by a complex charity structure, delivered by charity hospitals/clinics.

    The private STRUCTURE must be rebuilt. That means a TRANSITION of dollars back to the private sector ... at whatever speed it takes to complete the task. Not as easy as Rand Paul beating his chest, demanding, "I want TOTAL repeal!" … or his equally useless dad whining "NO." They impress the base … who are kept ignorant by the libertarian elites (Cato. Mercatus/Reason.com) But that's only "recent" (the past quarter-century)

    I described the dominant libertarian approach ... before pro-liberty libs were shouted down by anti-gubmint libs. Government haters CANNOT restore liberty. The private infrastructure cannot spring from the ground, like weeds. ONLY liberty lovers even care to try. Americans are open for even radical change, a once-per-century opening. The clock is ticking. And we already blew 2016, YUGELY,

  • chemjeff||

    But how does the Senate bill rate on Trump's "heart" meter or his "mean" meter? That's the real question.

  • Longtobefree||

    I will bet your next paycheck it does not contain the words "Obamacare and all associated regulations, rules, findings, and everything else are hereby repealed and declared null and void as of December 31, 2018". (It it too late to do it for 2017)

  • mortiscrum||

    The Republicans can't do that. They don't have 60 votes in the Senate.

  • Michael Hihn||

    Where do I send your trophy?

  • WakaWaka||

    "It would likely result in fewer people being covered, and it would not stop the destabilization of the market"

    This is a good article (far better than the previous articles about this topic), but this is faux talking-point that belongs on MSNBC and not Reason. The 'fewer people' that will be covered will be those who are not mandated to purchase insurance. It's a shell game. Otherwise, this was a good summary

  • Calidissident||

    I think it would probably be more from Medicaid being rolled back. I don't think the mandate is make or break for tens of millions of people.

  • RAHeinlein||

    At last count, the mandate itself covers 20 million+ self-insured. We own a small business and previously purchased catastrophic insurance only. The mandate is a killer due to high premiums/deductibles.

  • Calidissident||

    You're talking about the employer mandate, right? That may be true and that's a good point, but WakaWaka's comment seemed to be about people buying insurance due to the individual mandate.

  • RAHeinlein||

    I was referring to the individual mandate - I think the number was from SBAC.

  • Michael Hihn||

    I was referring to the individual mandate

    Which does not apply to your small business.

    - I think the number was from SBAC.

    Not even close. 2/3 of the expanded coverage from Obamacare was in Medicaid -- largely because the mandate penalty was too small to affect major change -- starting from a mere $95 per YEAR, and maxing out at $695..

    In 2008, Obama argued, correctly, that a penalty would have to be quite large to force purchase (they weren't) .. and even ridiculed the entire mandate notions of Hillary and Roberts with. "If mandates could work we could end homelessness by mandating everyone to buy a home." (paraphrased from memory)

    I don't recall if a mandate was in the bipartisan Obamacare proposal that Republicans rejected. What they rejected was (explicitly) a private alternative to a public option, before they forced Obama into dealing with his own far-right. What they rejected, at the very least, was "a seat at the table" in deciding the mandate. (And the likely kill of a public option forever.

    And repealing the mandate is TOTALLY stupid unless they also repeal pre-existing conditions. Premiums would SKYROCKET, since the mandate was intended SOLELY to offset the sick people with more healthy people. So the GOP death spiral would be WORSE. Sajme problem as Obamacare -- pander bears.

  • WakaWaka||

    And rolling back Medicaid is a bad thing, why?

  • Calidissident||

    That's funny, I don't ever recall saying it was. I was simply saying that the coverage loss is not mostly from the individual mandate as you stated.

  • WakaWaka||

    Got it

  • Michael Hihn||

    this is faux talking-point that belongs on MSNBC and not Reason.

    This is a faux talking point that belongs on Breitbart, Fox or Infowars.

    The 'fewer people' that will covered will be those who are not mandated to purchase insurance.

    Read it again.
    1) He doesn't say they should be covered, only reports a FACT, which may be "inconvenient" to your narrative.
    2) And you got the fact wrong. MOST of the people are the Medicaid cutbacks. But must be clarified by CBO.

    It's a shell game. Otherwise, this was a good summary

    If you want them to commit political suicide, create a Democrat wave next year ... SHITTING on the will of the people ... lose the power of governance ... and lose YUGELY ... but on principle!

    I haven't seen such dedication to principle since the People's Temple ... when hey drank the Kool-Aid, also on principle. Alos True Believers -- like the Moonies, the Branch Davidians and .,........

  • PersonalJayzus||

    The plan is perfect. It creates the need to keep coming back to Congress month-after-month, year-after-year, to buy delays, exemptions and interpretations.

  • chemjeff||

    I remember reading about conservative health-care reform ideas way way way back in 2005 or so that didn't actually suck. Like, expansion of HSA's and getting rid of the link between health insurance and employment. Republicans yelled for years and years about allowing competition between state lines. Trump even said he wanted to do it when he said that he wanted to get rid of "the lines around the states". None of that is in here. WTF, guys. This whole thing is borderline retarded coming from the Republicans. When Democrats used to complain that Republicans only opposed ObamaCare because it came from Obama, I used to think that they were crazy. Now, I'm not so sure.

  • Calidissident||

    I'm really not sure why they didn't go that route. At this point I'd honestly prefer them doing more targeted and limited measures like those that actually achieve something, rather than essentially creating their own version of Obamacare just so they can claim they repealed Obamacare.

  • Hugh Akston||

    Team Red can't touch tax exemptions for employer health insurance, because they'd have not only every large employer in the country up their butt, but a huge optics problem of Team Blue telling the middle class that those mean ol' republicans want to cancel your health insurance.

  • Calidissident||

    If they went the route of replacing tax exemption for insurance with exemption for contributions to employee HSA accounts, I think most employers would probably prefer that in the long-run. Of course the short-term upheaval could kill it for the reasons you mention.

  • chemjeff||

    I know, right? There are plenty of ways to do it that results in only minimal changes to what the employer experiences.

  • ||

    McCain proposed pretty much exactly that during the 2000 primary, IIRC, and there was general screaming about trying to monetize people's health savings, denying coverage to the poorest and most vulnerable, trying to cut costs for evil employers who want to wiggle out of caring about people, etc., etc.

  • Calidissident||

    So the same things said about any Republican plan?

  • ||

    Yup.

  • Michael Hihn||

    Team Red can't touch tax exemptions for employer health insurance

    It's simple., Increase the standard deduction by the average cost of employer premiums. The goal here is repeal market distortions, not revenues. The result would be the same after tax net for average coverage. Taxes would be cut to the currently uninsured, to help pay for coverage ... paid for by higher taxes on the union workers who everyone else subsidizes. The exploiters subsidize the exploited -- and revenue neutral!

    I used that in my campaign for WA State Insurance Commissioner as a Libertarian. Part of achieving major party status. I couldn't win, so I decided to test real policies with actual voters, and have fun. Had more fun than I dreamed. My POLICY proposals were MUCH more popular in debates.The line about the exploiters being subsidized got IMMENSE laughs, cheers, applause, whatever -- because I wagged my thumb and at the Dem and the Rep, and winked at the audience ... every time I contrasted the exploiters and the exploited!

  • Stormy Dragon||

    allowing competition between state lines

    This is and always has been a worthless talking point. Nothing is stopping me from buying out of state coverage right now. No one does because insurance that doesn't cover any of the doctors in your area is completely useless.

  • chemjeff||

    I agree that the talking point about "competition between states" was mostly just so Republicans could thump their chests a lot and yell "free market!" and not actually have to explain what their idea actually meant. But they didn't even try in this bill. Suderman is right, Republicans are starting with ObamaCare as an assumed premise and then just tinkering around the edges.

  • Michael Hihn||

    Across state lines is as fuclking crazy as Medicare vouchers. WRONG MARKET, Insurance is not healthcare.
    Can we affect new car prices with more competition between Allstate and GEICO?

    Republicans are THAT stupid on free markets. As is Cato (Medicare vouchers)

  • Lester224||

    Selling insurance across state lines: Good in theory, difficult in practice:

    https://tinyurl.com/y8yecanr

    At any rate, developing provider networks in new states takes time. May not be worth it to insurance companies.

  • Ron||

    lets face regulations that regulate regulations is key to continue needing congress to regulate for ever guaranteeing them a job. If they did their job right they'd be out of work.

  • BYODB||

    So should I read this article to mean that Suderman now believes that the ACA was terrible legislation, or is he just saying that the Republican version is more eviler because it was crafted by (R)'s? I mean, he lays out a case for full repeal, no replacement, but if memory serves he seemed to think that legislation like the ACA, and the ACA specifically, was a wonderful and grand thing?

  • Crusty Juggler - Alpha||

    but if memory serves he seemed to think that legislation like the ACA, and the ACA specifically, was a wonderful and grand thing?

    I don't believe that's accurate.

  • BYODB||

    Yeah, I think you're right. I think I got him confused with someone else after looking at the archive.

  • Crusty Juggler - Alpha||

    Suderman has done an excellent job reporting on this issue. He became a BetaCuckLeftieLib-dumbface when he wrote about Trump, which is why many seem to think he is a BetaCuckLeftieLib-dumbface.

  • BYODB||

    Nah, as insulting as it is I think I got him confused with Chapman somehow. Whoops. Sorry Suderman!

  • Glide||

    The difference is that Suderman (lately) exclusively attacks the right, but does it on libertarian grounds and realizes the left is no better.

    Chapman exclusively attacks the right, but relentlessly props up the left and gives libertarian grounds no value except as they serve his argument.

  • ||

    ^ This is a strikingly accurate characterization.

  • paranoid android||

    I think Suderman said that right after all the Reason writers voted for Obama and just before Shackford announced he opposes all freedom of association.

  • JWatts||

    "The Senate bill attempts to manage this instability by buying off health insurance companies with payments that Republicans previously argued were illegal and should be stopped."

    That's a bullshit misleading statement Suderman and you are smart enough that I believe it was intentionally misleading.

    The Republicans were correct in pointing out the payments to insurance companies was illegal. Spending has to be authorized by Congress and the Obama administration was making the payments without explicit legislation.

    However, if Congress approves such payment then it's perfectly legal.

  • ThomasD||

    Suderman being mendacious about Obamacare?

    The Hell you say!

  • chemjeff||

    Republicans: Rearranging the deck chairs on the S.S. ObamaCare!

  • ||

    It would seem libertarians who mysteriously woke up aboard the ship are content to lean against the railings with their arms crossed and shout, "I told you it would sink!" A few seem to be arguing about the best way to stay alive while floating in a life preserver at freezing temperatures.

  • chemjeff||

    Yes, libertarians should have at least a little bit of smug satisfaction that they were right all along about what happens when the government starts socializing medicine.

    But all the Republicans are doing is proposing to change course by just a couple of degrees or so, but still sailing full speed ahead into the field of icebergs known as government-run health care.

  • ThomasD||

    Starts socializing medicine???

    Obamacare wasn't the beginning, it was an effort to finish the job.

  • ||

    I like to think of myself as one of the musicians playing one last number as the water rises.

  • Libertarian||

    "In other words, it is exactly what critics predicted: a bill that, at least in the near term, retains weakened versions of nearly all of Obamacare's core features while fixing few if any of the problems that Republicans say they want to fix."

    But libertarians will continue to be called cynical and crazy.

  • Crusty Juggler - Alpha||

    I think we can all agree on one thing: healthcare is a right.

  • chemjeff||

    But does the healthcare have enough heart and isn't too mean? That's the real question here.

  • Libertarian||

    What's "sustainability", chopped liver?

  • JWatts||

    "Every state that has attempted this combination of coverage regulations without a mandate has seen a swift meltdown in the individual market. "

    Suderman makes a very good point here. There's every indication that requiring coverage of pre-existing conditions without a mandate to have pre-existing coverage leads to people gaming the system.

  • $park¥ leftist poser||

    Every time someone calls health insurance health care, a policeman shoots a puppy.

  • Tony||

    "But it won't go into effect until we're safely beyond our senatorial elections!" isn't going to convince voters that Republicans do not own healthcare now. And owning healthcare is bad when you're running for reelection.

    Apart from the fact that any failures in the system are now on GOP hands, the simple argument is that this plan cuts benefits in order to pay for tax cuts for rich people. Which happens to be true.

  • BYODB||

    Well, at least you admit that the system was failing under the ACA I guess.

  • Tony||

    In states run by Republicans.

  • WakaWaka||

    You're so dumb. So god damn dumb

  • Tony||

    I'm sorry, I didn't realize this was a defend-Republicans-at-all-cost type of place.

    Oh wait yes I did because I've been here a long time and that's all you morons ever do.

  • chemjeff||

    I did not know California was run by Republicans.

    http://www.latimes.com/busines.....story.html

  • Tony||

    "On Tuesday, officials blamed next year's premium hikes in the program that insures 1.4 million Californians on rising costs of medical care, including expensive specialty drugs and the end of a mechanism that held down rates for the first three years of Obamacare."

  • Juice||

    rising costs of medical care, including expensive specialty drugs and the end of a mechanism that held down rates for the first three years of Obamacare

    Here's where it would have been ironic to call it the Affordable Care Act instead of Obamacare.

  • ||

    In states run by Republicans.

    If only anyone had foreseen that passing this massive piece of legislation with a huge middle finger to the other party who opposed it in every way with every fiber of their being might cause problems later when you expect those exact seem people you gave the middle finger to to implement it for you.

  • Pro Libertate||

    Ye gods. A free market in healthcare and insurance are the only way anything is going to get better. There is no perfect solution, but socialism does not solve problems, it creates them.

  • Tony||

    So if you have a heart attack, does a free market mean you shop around for the ER with the best Yelp rating? If you black out on the street, who comes to your rescue in a free market in healthcare? The private physician you employ to shadow you at all times?

    This is exactly equivalent to saying that lollipops are the solution to all life's problems, and the only way to solve healthcare is to give everyone a lollipop. How nice it must be not have to put even the slightest amount of thought into your political worldview. Just "Free market good. Socialism bad. Grunt." Frees up a lot of time I bet.

  • ||

    This is exactly equivalent to saying that lollipops are the solution to all life's problems, and the only way to solve healthcare is to give everyone a lollipop.

    It is. It really is exactly like that. And not at all a sophisticated plan like expecting Government to wave its magic wand.

  • Juice||

    So if you have a heart attack, does a free market mean you shop around for the ER with the best Yelp rating? If you black out on the street, who comes to your rescue in a free market in healthcare?

    Wow. What a sorry lack of imagination.

  • Tony||

    Okay, imagine something for me. Say you're 80 and can't get insurance on the private market. What's the solution? Man up and die, right?

  • BYODB||

    So you admit Medicare is a failure?

  • BYODB||

    And you furthermore admit that Social Security is also a failure?

  • $park¥ leftist poser||

    Because if you can't get insurance, you can't get care. Right?

  • BYODB||

    Because as we all know, before the ACA no one went to E.R.'s and people just died in the streets.

    Dumb ass.

    Sorry Tony, not only have I worked in Hospital finance but my family owns a practice. Your knowledge of how healthcare markets function is just about as accurate and knowledgeable as a 10 year old child's. No exaggeration.

    The irony is that you probably think your redneck hick neighbors are idiots, when your own opinion is just as dumbed down and ignorant. Your opinion could be summarized as 'anything my hick neighbors don't believe in'. Your ethos exists solely as a middle-finger to people you don't like. It would be funny if it wasn't so sad and pathetic.

  • ||

    The one redeeming feature of the House bill was the ability for states to apply for waivers to escape the insurance regulations.

    So yeah, absent that feature, fuck this bill. It's basically putting a Republican blessing on socialized medicine.

  • RAHeinlein||

    Dropping the individual mandate is significant, but in-general aligned with your assessment.

  • ThomasD||

    The centerpiece of the law was a reform of the individual market, intended to give those who do not get coverage through work or a federal program access to subsidized, regulated coverage. The law created a new federal subsidy, based on income, for lower- and middle-income households to purchase health insurance. It set up federal rules requiring insurers to sell to all comers while limiting their ability to charge based on health history. It mandated that all individuals obtain health coverage or pay a tax penalty. And it erected a system of government-run health insurance exchanges on which consumers could purchase subsidized, regulated individual market coverage.

    Strange to see such a rosy presentation of what Obamacare actually is coming from an ostensible libertarian. Sounds more like an advertisement than any sort of objective assessment.

  • seahorsedan||

    It appears to me that the objective of the Republicans is to repeal the Democrats mandatory health care insurance tax on working class individuals and families aspiring to be middle class at the risk of their option not to insure their health and loose everything they work for. My preferred option is figure out a way to get a single payer HEALTH SYSTEM up and working as opposed to an insurance scheme that can not so much a dispense aspirin or apply a band aid. There is little in life that is as discouraging as going to work every day alone and finding on payday you have a bunch of partners all with the same last name. TAX. To me it is remarkable circular logic for the non-productive element of America to demand the productive element to cover the cost of their care and call that a tax break for the rich. No one labeled it a tax on the rich when Obama care was enacted so how is repealing it a tax break for the rich.

  • RAHeinlein||

    Well. Said.

  • Lord_at_War||

    My preferred option is figure out a way to get a single payer HEALTH SYSTEM up and working

    Because the VA in Phoenix is so helpful and efficient that 1500 died waiting in line, the top admins got 18 month paid vacations- and nothing else happened...

  • ranrod||

    Why Repeal if We are Going to Replace?
    The Constitution does not grant the federal government any authority to meddle in our health care, so it wouldn't matter even if the Republican replacement plan were a good one.
    In 2014, Gruber candidly declared that the legislation was written in a way that was designed to deceive the American people and to exploit "the stupidity of the American voter."Let me ask the simple questions: do you believe that government is a truth-teller?
    Do you believe that government intervention in a marketplace makes the market more efficient and just?
    Do you believe that government is the solution to our economic problems?
    If you do, then maybe Jonathan Gruber is right. Maybe you need someone like him, or your favorite political party, to lie to you for your own good.
    The operative clauses to look up here are Article One, Section Eight of the Constitution and the Tenth Amendment. It will only take you about six minutes to read and understand that any replacement of Obamacare is more than just a Republican betrayal for American health care; it is a dangerous and tyrannical trespass into American homes and lives.
    Make no mistake, repealing Obamacare is the Congress's duty, and to replace it is the action of tyrants.
    http://freedomoutpost.com/why-.....o-replace/

  • ranrod||

    Folks, even the most cursory research shows immediately that Trump is and always has been fully in favor of so-called "universal" or "single-payer" healthcare. These psychopathic fools have no intention of ever undoing Obamacare – only making it worse.
    I'm sorry, but if you were dumb enough to think that Trump or the congress would ever, ever, ever unwind the biggest racketeering matrix in human history, you deserve what you get. Keep writin' those quarterly tax checks! I'm sure if the Republicans can just pick up a few more seats… OH. WAIT.

    http://www.barnhardt.biz/2017/03/25/back-to-work/

  • Michael Hihn||

    it is a revealing sign of the shallowness of Republican thinking on health care policy.

    Then again, libertarians have absolutely nothing but slogans and soundbites for the tribe .,.. and Cato's TOTALLY hysterical Medicare vouchers. Vouchers LOOK like privatization to the the tribal faithful, by adding insurance companies. But Accounting 101 shows that means adding a costly, and useless middleman! (duh)

    Vouchers would increase competition ... in the wrong market! (OMG) Insurance is not health care!!! The same fuckup we ridicule progressives for -- confusing treatment with coverage.

    Medicare has ALWAYS has competition in the real market, providers, but seniors have no skin in the game. Can we impact the new car market with more competituon between Allstate and GEICO?

    WHO THE FUCK IS DEFENDING LIBERTY? The libertarian establishment aims at the wrong market, while also ignoring "skin in the game." The pathetic --and predictable -- blind alley of anti-gubmint libertarianism (as opposed to being PRO-LIBERTY). The same faction that was totally humiliated last November.

    Oh wait, this is a "libertarian moment." Never mind. Fund-raising now outranks liberty. And the libertarian brand is rejected by 91% of libertarians. (per Cato)

  • Dizzle||

    "Oh wait, this is a "libertarian moment." Never mind. Fund-raising now outranks liberty. And the libertarian brand is rejected by 91% of libertarians. (per Cato)"

    Maybe that brand is rejected because it's pushed by wannabe "intellectual" libertarians like you who espouse a "pure" form of libertarianism while completely ignoring the reality of the situation. That number also basically says 9% of libertarians are ideologues.

    And for petes sake, your solution here a few months ago was reopen all the religious/church funded hospitals, while you COMPLETELY IGNORED the fact most of those went out of business once church donations dried up and the ones that didn't had to pair up with a major healthcare network, insurance Company, or University to remain viable. Aka get their hands on a larger pile of subsidies.

    But you keep preaching from your high horse. You've obviously done so well having held a party position like 30 years ago, never getting elected to anything important, and generally pissing your pants and flailing your gums. You're smart, but you're also failing your mission terribly.

  • Michael Hihn||

    Dizzle makes a total ass of himself AGAIN!

    Maybe that brand is rejected because it's pushed by wannabe "intellectual" libertarians like you who espouse a "pure" form of libertarianism while completely ignoring the reality of the situation.

    Totally backwards, dumbfuck. Bend over!

    And for petes sake, your solution here a few months ago was reopen all the religious/church funded hospitals, while you COMPLETELY IGNORED the fact most of those went out of business once church donations dried up ….

    Fucking liar
    I said it would take YEARS to restore the private charities that provided universal treatment … the outcome of a free market. Thus, the only proper libertarian solution would transition dollars from government to private charity, at the exact pace of rebuilding the private sector. My way is a 100% tax CREDIT for donations to "life support" charities, which shifts dollars at the PRECISE pace.

    Correcting THAT fuckup Charitable donations did not "dry up." There was no perceived need for them after ... ever hear of Medicare and Medicaid?

    That number also basically says 9% of libertarians are ideologues.

    i attacked those ideologues ...now here ... so you call me an "intellectual" libertarian.
    Is it only "intellectuals" who call out your ignorance and bullshit?

    (My tone and boldface in defense of shameless aggression AND bullshit)

  • Get To Da Chippah||

    Dizzle, that stat Hihn keeps quoting is from the Hoover administration. It's meaningless at this point.

  • Michael Hihn||

    (Boldface in self-defense of aggression and lying)

    Aggressor
    Dizzle, that stat Hihn keeps quoting is from the Hoover administration. It's meaningless at this point.

    Everyone, the Cato Institute did not exist during the Hoover Administration The only stat I mentioned ... I said it was from Cato, Dizzle repeated it was from Cato, Bully says it was not. .

    This is the link to Cato's survey, conducted 72 years after the Hoover Administration. Several surveys are compared. For this one, scroll down (or page search) to the boldface header, How libertarians see themselves

    "In our Zogby survey we found that only 9 percent of voters with libertarian views identify themselves that way." -David Boaz and David Kirby (page search for the words)

    Libertarians (by that label) did not exist either, in the 1930s!!! What can we expect from someone who celebrates feeding humans into woodchippers, for disagreeing with him?

    Will he try to feed me into a woodchipper?
    Only if he wants his head blown off.
    Make my day.

  • Tionico||

    FedGov have NO AUTHORITY to put in place ANY laws relating to medical, healthcare, funding of either, or insurance of any kind. Those are all powers reserved to the States, or to the People.

    Oh Bummer Care is illegal on its face... and became MORE illegal when that Supreme Court hooh hah John Roberts sold his soul down the river and declared it a "tax" (forgetting that ALL bills involving taxation MUST originate in the HOUSE.. and Oh Bummer Care rose up in the Senate.

    The R guys are the ones with the imaginations...... thinking they can make legal and functional what is, on its face, or deeper in, neither. They KNOW why we sent them to DC this time around (in case they missed it in elections past when things were a little less clear). FULL REPEAL and no replacement of any kind. Nothing less, and certainly nothing more. End it. Its done. Put the fork in.

    THEN get to work on removing all FedGov barriers to an open and free market in all these areas.... including repealing all the stupid laws that prevent insurance companies marketing and handling their accounts interstate. Our car and home and personal liability insurance can ALL be bought from out of state. WHY must "health insurance" be bound up like it is? I'll tell you... preserving market territory. Sorry, that does not help ME.

  • Michael Hihn||

    Blah - blah - blah. Let's test your Liberty IQ

    Hypothetically, assume an entire Congress is elected on the same platform -- single-payer healthcare. Would it then be proper for Congress to do so? Why not? (I assume you answered wrong.)

    Do governments derive their just powers from the consent of the governed? Is that principle superior to the Constitution? Because if it's not, then the Constitution is NOT a just power, correct?

    Jefferson also believed each generation had to wage its own Revolution and derive its own Constitution. Why?
    Because without that, future generations would have no commitment to a constitution! So self-righteous pronouncements of "what the Founders intended" are totally useless, kinda dumb and actually authoritarian.

    NO free people will EVER commit to diktats from on high -- that they had NO say in. Just as YOU, on the job, would feel NO commitment to diktats handed down from on high. In well-managed organizations, goals are NEGOTIATED with employees. Guess why. So they fully commit to achieving -- and defending -- those goals.
    It's called "skin in the game." (gasp)

    This is AMERICA. We don't NEED a revolution. The Rights of Man are superior to government.

    You, Ron Paul and his ilk are authoritarians. You have NO power to shit on Will of the People and Consent of the Governed.

    Any questions?

  • dstarke||

    The undeniable truth is that there are a significant number of Republicans who want to own Obamacare, relieving the Democratic Party of it's burden. Why they want this is unfathomable to me, yet there it is.

    Perhaps the Republican wing of the Uniparty feels more comfortable as a permanent minority

  • Michael Hihn||

    Republicans who want to own Obamacare,

    They already did worse.
    Obamacare approval has soared ... because Americans now see it as the best alternative ... and see the Republicans' .... nothing. GOP healthcare has approval by only 16% of all voters ... and less than 25% of Republicans.

    Then again, fucking Hillary had a private server,

  • Wearenotperfect||

    I'm all for scrapping the ACA and eliminating government from my health care choices but if America really cares about it's citizens and wants to provide some kind of health care (some kind of basic health care in my view) then take an extra 20 bucks out of my paycheck every week and if I want additional coverage, and I can afford it, then I will purchase it. I may be pissed off for a while but I'll get over it, simple!

  • buybuydandavis||

    The Senate GOP's New Health Care Bill Is Just Obamacare, But Less Of It
    The draft legislation represents a total failure of Republican policy imagination.
    ...
    Partly this was for procedural reasons: Reconciliation, the budget maneuver which Republicans are relying on to pass a bill in the Senate with a simple majority vote, presents some procedural barriers to full repeal.

    Less Obamacare is all that can possibly get passed. No bill overturning Obamacare will get a single Democrat vote. All that can be done has to get done through reconciliation and regulatory changes. That means a limited overhaul. When those facts on the ground change, maybe they'll be able to get Democratic support for full reform.

    Opposition to Less Obamacare now is de facto support for Obamacare now and forever.

  • Lester224||

    Most of the Republicans just want to pass a bill to say they kept campaign promises. They don't really care what's in it.

  • tlapp||

    It may be better this Obamcare bailout fails. Then we can finish watching the Obamcare meltdown. Then we may have a chance if we get rid of more of the statist republican establishment.

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