a new hope for healthcare

a new hope for healthcare

Just a couple of weeks away from the Affordable Care Act’s open enrollment period – now just half as long as usual, thanks to the Trump administration’s active sabotage – the politics around healthcare remain opaque, and in fact are possibly even more confusing this week than last, when President Trump cut off federal subsidies for insurance programs that helped the sick and the poor.

There is, however, some good news: a pair of bipartisan senators, Republican Lamar Alexander of Tennessee and Democrat Patty Murray of Washington, have completed a draft of a proposal that would stabilize the markets for the next two or three years (during which time Republicans will presumably be working on a longer-term, and much more ideologically consistent, replacement). The bill draft, officially released on Thursday with an impressive list of 24 bipartisan co-sponsors (12 from each party), does a handful of things, according to a summary document provided to NPR:

  • It restores the federal subsidies Trump just eliminated, called cost-sharing reductions (or CSRs), through 2019;
  • It reinvests in outreach and enrollment, which is another area the administration has sought to sabotage by various means, most notably trimming the length of the open enrollment period, pulling ads and cutting the program’s advertising budget by 90 percent, and announcing, sort of inexplicably, that it will be shutting down the enrollment website for 12 hours at a time every Sunday during the open enrollment period;
  • It tweaks the law’s 1332 waiver provision to “allow states to propose innovative value-based insurance designs” and streamlines the review process – the 1332, by the way, is another aspect of ACA the Trump administration has been sabotaging;
  • It expands eligibility for catastrophic plans for people over 30, and mandates that, despite expanded eligibility, that particular market remains a single risk pool, so premiums won’t go up for folks “with serious medical risks”;
  • It directs the Trump administration to build a regulatory framework around interstate health compacts, something the ACA as is does not do.

It’s not tough to tell why different aspects of this would appeal to both parties: keeping the CSRs in place for now goes a long way to stabilizing the marketplace and ensuring millions of low-income people get to keep their health insurance – that’s one in the plus column for Democrats, who’re invested in seeing ACA function – and streamlining the 1332 waiver provision process, combined with enshrining interstate health compacts, gives states and businesses more flexibility to try out various other healthcare solutions – a big win for Republicans subscribing to free market principles. Plus the optics on a bipartisan bill are mostly pretty good for a Congress that’s struggled with gridlock and hyper-partisanship for nearly a decade now.

Conservative take:

Liberal take:

The Editors at the National Review came out against the bill, arguing that “in exchange for appropriating the Obamacare funds, Republicans would get…nothing much.”

At the New Yorker, Ryan Lizza argues that we should pay close attention to the developing relationship between Trump and congressional Democrats, claiming that “the real deal will happen December,” during the budget negotiations.

The problem is that most Senate Republicans likely won’t support the bill – mostly because, as Dylan Scott points out at Vox, they’ve spent years talking about repealing Obamacare, not fixing it – and so it won’t make a whole lot of sense for Mitch McConnell to bring to floor vote a bill that most of his caucus can’t vote for without looking hypocritical. Again, it’s optics: with the GOP establishment under siege by Bannon and co., it’s a tough sell to get McConnell to do something that alienates an increasingly extremist base and gives the hardliners serious ammo in 2018.

The other problem is the president, whose support has waffled despite behind-the-scenes work to get the thing done. When asked on Tuesday what he thought about the Alexander-Murray effort, he had this to say:


So they are indeed working, but it is a short-term solution so that we don't have this very dangerous little period -- including dangerous periods for insurance companies, by the way. For a period of one year, two years, we will have a very good solution.


By Wednesday, though, he’d reversed his position: on Twitter, he wrote that he was “supportive of Lamar as a person & also of the process, but I can never support bailing out ins co’s who have made a fortune w/O’Care,” and on Thursday, Marc Short, a senior White House aide, refined the message when he said on CNN that Trump “would demand steps toward repealing Obamacare in any healthcare legislation.”

If you’ve been following politics then you know that Trump’s reversal is not all that surprising (see: DACA), and as Chris Cillizza observes at CNN, Trump has been against the CSRs all along, and it’s possible that “he had no real idea what was in Alexander’s legislation.”

What this means is that, despite the fact that the votes are there, the bill’s probably not going to be put in play – at least not yet. However: there will be an opportunity in December, when negotiations over the FY2018 budget will take place. As Dylan Scott writes in that same Vox article, “government spending bills need 60 votes, so the minority has a lot of leverage” – which means the Democrats can bargain for Alexander-Murray, depending on how they prioritize their wish list (DACA’s another looming issue, as is the Children’s Health Insurance Program, which used to provide health insurance to 9 million children, until Congress let it expire three weeks ago).

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