Republicans' health care proposal is doomed

Few folks on either side of the ideological divide would call Obamacare an unqualified success. And that's a fair assessment.

The 2010 Affordable Care Act had two aims: Insure more Americans, and control and rationalize the health care market and its costs. The first, unquestionably, has happened. The second? It's complicated — premiums have increased, but maybe not so much as without the ACA's reforms.

But Obamacare's biggest victory — the one Republican lawmakers are now scrambling to counter — is this: The ACA has extended health care coverage to 20 million Americans. Simply repealing it is no longer an option.

And that's a problem for Congressional Republicans who don't come close to agreement about what health care should be, who deserves to have it and who is responsible for providing it. That's one reason Obamacare drew such heated opposition; even its staunchest critics knew that once passed, it would be nearly impossible to pull back.

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Think of how GOP rhetoric has shifted, over the years, from "repeal" to "repeal and replace" — leaving the 20 million Americans with ACA-related coverage high and dry is a political nonstarter. Although Obamacare and its prospective replacement are market-based, we've inched closer to defining health care as a public good.

So the American Health Care Act, released Monday by Republicans in the U.S. House of Representatives and advancing through the U.S. Congress at a record clip, has an impossible task — reconciling President Donald Trump's campaign promise that his Obamacare replacement would cover "everybody," at lower costs, with the conservative mandate to limit government's role in health care.

All of those promises are running aground on the reality of the health care market, and the political need to ensure Republican voters aren't hung out to dry — here in Michigan, counties where voters turned out for Trump have the highest percentages of residents who rely on Obamacare or its accompanying Medicaid expansion for insurance coverage, an analysis by Bridge Magazine found.

The American Health Care Act is bad policy. Congressional Republicans who see that should stop it from advancing.

Republican opposition to the ACA has relied, frequently, on the notion that folks who don't want health insurance shouldn't be forced to buy it, and that policy premiums are too high — but the former is the only way to control for the latter. Some Republicans have said the government has no business in health care — but the AHCA simply replaces Obamacare's subsidies with refundable tax credits. A driving impetus behind the Affordable Care Act was to insure the uninsured — but the AHCA will offer generous subsidies and tax cuts to top earners who are less likely to need help, while cutting programs and dollars meant for folks at the bottom of the socioeconomic ladder. And a persistent GOP talking point is that folks need to have skin in the game, that if you pay more out-of-pocket, you'll claim fewer benefits — but that's a starting point unlikely to ensure public health.

It's an hodgepodge of talking points and ideological fragments circumscribed by political reality that cannot make good on its promise.

The legislation keeps some popular Obamacare provisions: Insurers still won't be able to decline to provide coverage because of pre-existing conditions, young people will be able to stay on their parents' insurance until age 26, and lifetime caps on coverage will stay gone. The AHCA also, surprisingly, keeps an Affordable Care Act requirement that insurance plans offer birth control at no additional charge.

But that's the good news.

Start with the analysis by Standard and Poor's that says 6 million to 10 million Americans will lose health care if the AHCA passes, and that a wide range of stakeholders, from senior citizens to medical associations to right-wing groups, don't support it.

Or the fact that U.S. House Republicans are advancing the bill without a score from the Congressional Budget Office, which projects the cost and impact of legislation.

Take the Health Savings Accounts that are a favorite of House Speaker Paul Ryan, Republican of Wisconsin, which allow people to save more of their own pre-tax dollars to pay for health care. That's barely a benefit, but Ryan presents it as a great liberation for folks shackled by the oppression of insurance coverage.

Or the way the AHCA handles the Medicaid expansion, maintaining federal funds to support the Medicaid expansion that offered coverage to folks earning 130% of the federal poverty level — a key component of the ACA that insured around 650,000 people here in Michigan — until 2019, then freezes it, with the expectation that the ranks of those insured by the program will thin over time. Some analysts see it as the expansion's death knell; others say it's a punt, placing the political liability for kicking 650,000 people off the rolls on a future Congress.

And look at the loathed-by-the-right individual mandate, which the American Health Care Act ditches in favor of incentivizing for the insured to maintain continuous coverage through a steep premium for anyone whose policy has lapsed for more than 63 days. Lapsed coverage for longer means paying a 30% penalty on a new policy's premium, a feature that seems likely to convince a healthy uninsured person to stay uninsured, and which moves the revenue stream generated by the tax penalty for folks who flouted the mandate from the public coffer to insurers' hands.

Or those refundable tax credits for low-income insurance customers — something else that conservatives like as little as direct subsidies — that are less generous for the elderly, who are more likely to be sick and need coverage, than those for the young. The tax on capital gains, investment income and dividends levied on top earners that helped fund the Medicaid expansion and subsidies would be repealed.

Medicaid at large would be changed from fee-for-service to block grants; instead of paying a percentage of the cost of service, the federal government would allot states a fixed amount of money to cover costs billed by Medicaid recipients. The notion that this would cover an equivalent level of care doesn't stand up to even casual analysis.

The American Health Care Act promises to insure fewer people, at greater cost. In short, it's a mess.

Those features of Obamacare that most offend its critics are the safeguards that could make a market-based health care system functional. Substantial alterations mean insuring fewer people, and that some of those who retain coverage will pay more. The Affordable Care Act is dense and complicated legislation. To reaching the goal of increasing market-based health care coverage, it had to be.

That's why the American Health Care Act is such a headache. Policy should have a point, serve a constituency, address a need. This bill, on its face, accomplishes none of those things. So the question for GOP leadership is, what are they really trying to do? And why should we let them?