The new strategy for repealing the Affordable Care Act seems to involve asking Republican senators to pass a relatively narrow piece of legislation that would leave 15 million people uninsured and cause premiums to rise 20 percent ― all in the hopes that House and Senate leaders could later come up with a different bill that would pass muster in both chambers.
After weeks of unsuccessfully trying to rally support for various versions of repeal legislation ― and ahead of a key procedural vote Tuesday to launch a formal debate on legislation ― Senate leaders are floating the idea of a "skinny bill," according to multiple media accounts, as well as GOP sources who have spoken to HuffPost.
Like every other proposal that has emerged in this rushed, mostly private effort to craft legislation, the precise details of the skinny bill and strategy for passing it are generating a ton of conversation ― but it's not entirely clear that everybody speaking about it is as informed as they think.
The basic idea is to pass a bill that would deal with just a few key elements of the Affordable Care Act and not stir up the biggest, most controversial issues that have divided the Republican caucus so far. House and Senate leaders would later try to find some way to negotiate a new, mutually acceptable version of legislation that they could bring back to each chamber.
The House passed its version of legislation, the American Health Care Act, in May. Senate Republicans promptly made clear that they intended to write their own version of legislation, apparently in the hopes that they could force the House to pass it, then got stuck while determining exactly what they want to do.
The main focus of the skinny bill would be the Affordable Care Act's mandates ― in particular, the individual mandate that penalizes people who have access to insurance but decline to buy it. The mandate is among the law's least popular features. Ending it has been a rallying cry for conservatives since former President Barack Obama signed the health care law in 2010.
The skinny bill would also end a requirement that employers provide coverage for employees, as well as a tax on the medical device industry. But it's the repeal of the individual mandate that would be most consequential, as policy as well as politics.
The Affordable Care Act created the mandate as a way to make possible reforms of the private insurance, especially the guarantee of coverage for people with pre-existing conditions. Without some kind of incentive to make sure healthy people get insurance, many would hold off buying coverage ― at least until they got sick.
Insurers would be stuck with groups of beneficiaries in unusually poor health, forcing them to raise premiums in ways that would scare off yet more healthy people, creating what insurance industry experts call a death spiral.
CBO on repealing the individual mandate ("skinny repeal"): 20% premium spike and 15 million uninsured increase. https://t.co/mMOEqnuAIZ
- Larry Levitt (@larry_levitt) July 25, 2017
Taking away the mandate while leaving the rest of the Affordable Care Act's regulations in place would likely create such a dynamic. Two years ago, the Congressional Budget Office examined a proposal similar to the one Senate leaders currently seem to have in mind. Without a penalty for people who don't get coverage, and with insurers raising premiums because of their changing risk pools, the CBO predicted that the number of people without insurance would rise by 15 million people and that premiums would increase by 20 percent.
Many conservatives have suggested the CBO overestimates the effect of the mandate. But while all projections carry uncertainty, the CBO's models are based on real-world experience. The recent behavior of insurers ― they're raising rates for next year out of fear that the Trump administration will not enforce the existing mandate ― would seem to provide yet more proof that the mandate has an impact, even if the magnitude of that impact is not certain.
A skinny repeal bill would not touch the Medicaid program, which both the House bill and full repeal proposals from the Senate would cut significantly. Those cuts have been a major point of controversy in the Senate, particularly among more moderate Republicans whose states expanded the program and where millions are now getting insurance through it.
That is one reason why it's impossible to know how passing such a bill would play out afterward ― whether House and Senate negotiators would be able to come up with a new compromise, what such a compromise would look like, and then whether it could get majorities in the two houses.
The idea of dropping full repeal in order to pass a skinny bill and get to some kind of House-Senate negotiation is the latest crazy twist in what can only be described as a crazy legislative process ― one that has defied conventions of how legislation is supposed to be written, and now envisions the Senate voting on a bill affecting one-sixth of the economy with mere days (or maybe mere hours) or warning over what the legislation would say.