A group of insurance experts is warning Congress against repealing ObamaCare’s individual mandate, saying the move would raise premiums and could cause insurers to drop out of the market.
The American Academy of Actuaries wrote to congressional leaders on Tuesday saying that “eliminating the individual mandate would lead to premium increases.”
The Republican tax-reform bill which is nearing completion in Congress would repeal the ObamaCare mandate that people have health insurance or pay a fine.
Republicans argue the measure included in the Senate-passed bill is tax relief by removing a penalty for low-income people who choose not to buy insurance.
The actuaries warn that repealing the mandate would harm the health insurance market by removing an incentive for healthy people to enroll and balance out the costs of the sick.
The insurance experts also say that a measure pushed by Sen. Susan Collins (R-Maine), intended to help offset the premium increases from repealing the mandate, would not be enough to make up the difference.
That bill, sponsored by Sens. Lamar Alexander (R-Tenn.) and Patty Murray(D-Wash.), would fund key ObamaCare payments known as cost-sharing reductions. The actuaries say the payments “would not offset premium increases due to an elimination of the mandate.”
The letter says additional measures — such as funding to bring down premiums known as “reinsurance,” which Collins has also proposed — could help, though. Some experts say more funding than is currently proposed would be needed.
The instability from repealing the mandate also could lead some insurers to drop out of markets altogether, the actuaries warn, potentially leaving some people with no insurance options.
“Insurers would likely reconsider their future participation in the market,” the actuaries write. “This could lead to severe market disruption and loss of coverage among individual market enrollees.”
House Republicans on Tuesday unveiled a package of bills to delay a range of ObamaCare taxes, which could be acted on later this month.
House Ways and Means Chairman Kevin Brady (R-Texas) led the announcement for the bills to delay ObamaCare’s tax on medical devices for five years, on health insurance for two years, and the “Cadillac tax” on high-cost health plans for one year. The package would also eliminate penalties for employers who do not offer health insurance to their workers, under the employer mandate, through 2018.
The bills are only supported by Republicans at the moment, but they come after bipartisan negotiations with Democrats on delaying the taxes, a move that has support on both sides of the aisle. The package could be attached as part of a bipartisan deal on a year-end government funding bill.
The delay of these taxes would be a victory for industries, like medical device companies and health insurers, that have pushed against the taxes. Those groups are still pushing for full repeal eventually.
The delay of the taxes is not paid for in the bills introduced on Tuesday.
The Cadillac tax has been a particular sticking point, with Democrats leading the charge to delay it. Republicans on Tuesday agreed to delay it for one year.
“Obamacare’s failures are continuing to hurt families across the country – and allowing burdensome health care taxes to continue or go back into effect would make these problems even more severe,” Brady said in a statement.
The Affordable Care Act, aka “Obamacare,” has roiled America since the day it was signed into law in 2010. From the start, the public was almost evenly divided between those who supported it and those who opposed it.
They still are. The November monthly tracking poll from the Kaiser Family Foundation found that 50 percent of those polled had a favorable view of the health law, while 46 percent viewed it unfavorably. Partisan politics drives the split. Eighty percent of Democrats were supportive in November, while 81 percent of Republicans were strongly negative. (Kaiser Health News is an editorially independent program of the foundation.)
That helps explain why Republicans are working to repeal a key element of the health law in the tax bill Congress is negotiating. The requirement that most Americans have health insurance or pay a tax penalty — the so-called individual mandate — is by far the most unpopular provision of the law, particularly among Republicans.
Still, while partisanship is a major reason why some people hate the health law, it’s far from the only one. Here are four more:
Ideology
Conservatives and libertarians strongly object to the federal government becoming ever more involved in the nation’s health care system. While the refrain that the ACA represented a “government takeover” of health care was a significant exaggeration, the law did insinuate the government significantly further in its funding and oversight of health care.
Adding to that was the unhappiness with the ACA’s individual mandate. Although the idea was originally suggested by Republicans in the late 1980s, the GOP had mostly backed away from it over the years (with the notable exception of Massachusetts Gov. Mitt Romney, who supported that state’s health overhaul in 2006).
But conservatives are not alone in opposing the ACA on ideological grounds. Many liberals don’t like the law, either. They think it does not go far enough toward a fully government-run system and gives too much power to private insurance companies.
Lack Of Knowledge
A big part of why people don’t like the health law is that they don’t understand what it does or how it works. Some of that is because health care is complicated.
Even some of the main arguments made by the law’s supporters are not well understood. For example, the health law is responsible for some 20 million Americans gaining health insurance. Yet in 2016, when the uninsured rate hit an all-time low, only one-quarter of respondents to the Kaiser tracking poll knew that. A little under half thought the rate had remained unchanged, and 21 percent thought the rate had risen to an all-time high.
But some misperceptions follow intentional fabrications or exaggerations of the law’s impact. Many people came to believe (incorrectly) that the law would create “death panels” to decide the fate of seniors on Medicare, which became PolitiFact’s “Lie of the Year” in 2009. Other outlandish and untrue claims about the law included the idea that it would require people to be microchipped, that it would create a “private army” for President Barack Obama and that it would require hospitals to fire obese employees.
Even the derisive nickname “Obamacare” fed the confusion. In a now-famous skit by comedian Jimmy Kimmel, people on the street expressed a strong preference for the Affordable Care Act over Obamacare — unaware that they were the same thing.
Confusing The Health Law With The Rest Of The Health System
Once the ACA became law, basically everything bad that happened in health care was attributed to it. This is the famous “you broke it, you bought it” problem — the law became the scapegoat for any number of problems in the health care system, regardless of whether they predated its enactment.
For example, rising prices for prescription drugs has been a problem for years. But the ACA did not seek to address that, except for one provision that sought to facilitate generic copies of some of the most expensive biologic medications.
Also, before the ACA, some insurers stopped offering plans in the individual market, while others raised premiums dramatically and often would not cover care at high-cost providers like teaching hospitals.
Some People Actually Are Worse Off
The ACA did create some losers. Healthy people who managed to buy individual health insurance before the law’s passage have seen their premiums and out-of-pocket costs soar as insurers have raised prices to accommodate sicker people who had been largely shut out of coverage. Among those hardest hit are people who earn just slightly too much to qualify for federal premium subsidies, particularly early retirees and people in their 50s and early 60s who are self-employed.
Many of those people would have been helped if Democrats had been able to pass some of their original ideas for the ACA, including a “public option” plan run by the government, or a “Medicare buy-in” that would have given people age 55 and older the option of purchasing Medicare coverage before the normal eligibility age of 65. Both were rejected by more conservative Democrats in the Senate.
Some people found themselves in a “coverage gap” after the Supreme Court in 2012 ruled that the ACA requirement for states to expand Medicaid had to be optional. That meant people with incomes under the poverty line but still too high to qualify for Medicaid in their states have no affordable program available.
Others were forced to give up coverage that they liked, even if it did not offer many benefits, or were angry because their doctors and hospitals were no longer in their insurers’ networks. Obama’s promise that “if you like your health plan you can keep it” was PolitiFact’s “Lie of the Year” for 2013.
However, even some of those consumers have seen benefits from the law, although they might not realize it, like required rebates from insurers who charge too much for administrative costs.
But it is human nature for people who feel wronged to complain loudly, while people who are satisfied merely go on with their lives. In the end, that is why it seems so many more people hate Obamacare than actually do.
A fight over ObamaCare is spilling into Congress’s December agenda, threatening lawmakers’ ability to keep the government open.
President Trump signed stopgap legislation Friday aimed at averting a shutdown and keeping the government funded through Dec. 22. The bill allows lawmakers to focus on the next — and seemingly more difficult — negotiating period.
Lawmakers on both sides of the aisle have a host of priorities they want to include in the bill, but the question of funding ObamaCare’s cost-sharing reduction (CSR) payments appears to have divided Republicans.
Senate Republicans want to include the cost-sharing payments in the spending package, but House conservatives have little interest in funding subsidies they see as bailing out a law they despise.
Senate Republican leaders view the payments as a necessary bargaining chip.
In order to pass their tax-reform bill and get a much-needed legislative victory, Senate Majority Leader Mitch McConnell (R-Ky.) made a deal with Sen. Susan Collins (R-Maine), a key swing vote.
In exchange for Collins’s vote for the tax bill, McConnell gave an “ironclad commitment” to pass a pair of bipartisan bills.
One bill, sponsored by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), would temporarily fund the cost-sharing payments. Another would provide “reinsurance” — money to pay for the costs of sick enrollees and bring down premiums.
Together, the bills would shore up ObamaCare’s insurance markets, which experts predict could be gutted by a provision of the tax bill that repeals the mandate to buy health insurance.
But the commitment to Collins came from McConnell, who can’t force the House to take up legislation. Speaker Paul Ryan (R-Wis.) hasn’t given any indication that he would support passing the ObamaCare bills, though he also hasn’t ruled it out.
“I wasn’t part of those conversations,” Ryan told reporters Thursday when was asked about McConnell’s promise to Collins. “I’m not deeply familiar with those conversations.”
Earlier in the week, Ryan reiterated his commitment to repealing ObamaCare, but didn’t tip his hand on the spending bill.
“We think health care is deteriorating. We think premiums are going up through the roof, insurers are pulling out and that’s not a status quo we can live with,” Ryan said.
House conservatives have also said they have little energy for passing a government funding bill that contains any ObamaCare provisions.
“None of us voted in favor of ObamaCare, so supporting it, sustaining it’s not exactly a high objective,” said Rep. Tom Cole (R-Okla.), a leadership ally.
Rep. Mark Walker (R-N.C.), chairman of the conservative Republican Study Committee, said that he had been assured by House leaders that ObamaCare payments would not be attached to the next funding bill.
“The three things that we’ve been told are not going to happen as part of our agreement: no CSRs, no DACA, no debt limit,” Walker said, referring to the Deferred Action for Childhood Arrivals (DACA) program, which offered protections for immigrants brought into the country illegally as children. Trump ended the program with a six-month delay in September.
When asked about any assurances made to Walker, Ryan’s office declined to comment on member discussions.
Separately, Walker said any effort to add ObamaCare provisions to the spending bill would cost Republicans more votes from the GOP than they would gain with Democratic lawmakers.
If the Senate includes ObamaCare payments in the funding package, it could force a showdown with House Republicans, who would be under pressure to pass the Senate’s bill or risk a shutdown.
For now, Democrats are trying to maximize their leverage and are content to let Republicans fight among themselves.
Republicans need at least eight Democrats to break a filibuster in the Senate for any spending bill, and often rely on Democrats to make up for GOP defections in the House.
Alexander, who has long pushed for his bill to be included in a year-end spending bill, dismissed the idea that Republican senators need to pressure their House colleagues.
“The president’s for it, Sen. McConnell’s for it, most Republicans in the House have voted for both two years of cost sharing” and reinsurance in the past, Alexander said. “I feel pretty good about it.”
House and Senate negotiators thrashing out differences over a major tax bill are likely to eliminate the insurance coverage mandate at the heart of the Affordable Care Act, lawmakers say.
But a deal struck by Senate Republican leaders and Senator Susan Collins of Maine to mitigate the effect of the repeal has been all but rejected by House Republicans, potentially jeopardizing Ms. Collins’s final yes vote.
“I don’t think the American people voted for bailing out big insurance,” said Representative Dave Brat, Republican of Virginia, who opposes a separate measure to lower insurance premiums that Ms. Collins thought she had secured.
“Mandating people to buy a product was a bad idea to begin with,” said Representative Rob Woodall, Republican of Georgia. “We made people do something that was supposed to be good for them. But they are telling us by the millions how much they dislike the mandate.”
Representative Kevin Brady of Texas, the chief architect of the House tax bill, asked whether he was receptive to the idea of eliminating the penalties for going without insurance, said, “I certainly am.”
The individual mandate was originally considered indispensable to the Affordable Care Act, a way to induce healthy people to buy insurance and thus to hold down insurance premiums for sicker customers. The Obama administration successfully defended the mandate in the Supreme Court. But recent economic research suggests that the effect of the mandate on coverage is somewhat smaller than previously thought.
With little more than a week remaining until the annual open enrollment period ends, 3.6 million people have selected health plans for 2018 in the 39 states that use the federal marketplace, the Trump administration reported Wednesday. That is 22 percent higher than at this point last year, despite uncertainty about the mandate’s future and efforts by Republicans and the administration to undermine the law.
But because the sign-up period is only half as long, it appears likely that enrollment will end up lower than in the last period.
Without a mandate, some healthy people are likely to go without coverage, leaving sicker people in the market, and prices are likely to rise more than they otherwise would. The Congressional Budget Office said last month that repealing the individual mandate would increase average premiums on the individual market about 10 percent, and it estimated that the number of people without health insurance would rise by 13 million.
Regardless, the requirement has proved to be one of the most unpopular parts of the 2010 law, and House Republicans were happy to see it go. Representative Richard Hudson, Republican of North Carolina, called the Senate provision “a great move.”
The repeal also frees up money that Congress can use to reduce tax rates. The budget office said it would save the federal government more than $300 billion over 10 years — mainly because fewer people would have Medicaid or subsidized private insurance.
The mandate repeal’s effect on health insurance markets did concern Ms. Collins, and to win her vote for the Senate tax bill, the Senate majority leader, Mitch McConnell of Kentucky, offered her a deal, in writing: He would support two bipartisan bills to stabilize markets and hold down premiums, in the absence of the individual mandate.
One bill would provide money to continue paying subsidies to insurance companies in 2018 and 2019 to compensate them for reducing out-of-pocket costs for low-income people. President Trump cut off the “cost sharing” subsidies in October, more than a year after a federal judge ruled that the payments were unconstitutional because Congress had never explicitly provided money for them. The payments would resume under this measure, drafted by Senators Lamar Alexander, Republican of Tennessee, and Patty Murray, Democrat of Washington State.
The second bill would provide $5 billion a year for grants to states in 2018 and 2019. States could use the money to help pay the largest health claims, through a backstop known as reinsurance, or to establish high-risk pools to help cover sick people.
Ms. Collins has released a copy of her agreement with Mr. McConnell in which he pledged to support passage of the two measures before the end of the year. His signature was displayed prominently at the top of the first page. But the deal has landed with a thud in the House, where Republicans appear loath to support legislation that they view as propping up a health law that they have pledged to repeal.
“Our members wince at voting to sustain a system that none of them supported,” said Representative Tom Cole, Republican of Oklahoma.
The Senate could attach the Alexander-Murray legislation to a government funding measure, hoping that Republicans in the House would be willing to swallow it as part of a measure to avoid a government shutdown. But Mr. Cole said House Republicans would be “very offended” at such an approach.
“I don’t think we’re in the mood to be blackmailed by anybody,” he said.
Mr. Brat, a member of the conservative Freedom Caucus, assailed the deal with Ms. Collins as an example of horse trading that is characteristic of the Washington swamp that he said voters had repudiated.
Likewise, Representative Mark Walker of North Carolina, the chairman of the conservative Republican Study Committee, said of the Alexander-Murray bill, “There’s no appetite for that over here.”
Ms. Collins said on Wednesday that she believed the House would “take a serious look” at the two bills intended to hold down insurance premiums and that Mr. Trump, in several recent meetings, had assured her that he also supported those bills.
“I don’t think this effort is over by any means,” Ms. Collins said.
For Democrats, eliminating the insurance mandate penalties provides yet another reason to oppose the tax bill.
“The individual mandate is at the heart of the Affordable Care Act,” said Representative James E. Clyburn, Democrat of South Carolina. “Repealing it, as the G.O.P. tax scam does, is a deliberate attempt to undercut the law, create chaos in the health insurance marketplaces, increase premiums and decrease choice and coverage.”
Ms. Murray indicated that even if Ms. Collins secures her deal, Democrats would remain steadfast.
“Our bill, the Alexander-Murray bill, was designed to shore up the existing health care system,” not to “solve the new problems in this awful Republican tax bill,” she said.
Meanwhile, the damage to the Affordable Care Act may already have been done. Daniel Bouton, an enrollment counselor in Dallas, said he worried that the Trump administration’s decision to cut advertising for open enrollment had prevented millions of people from learning about the shortened sign-up period. He also said that the Senate’s recent vote to undo the individual mandate as part of its tax bill would discourage people from signing up.
“You’re going to have people who say, ‘Well, perfect, I don’t have to buy insurance anymore,’” Mr. Bouton said.
Healthcare lobbyists are scrambling to win changes in congressional Republican tax legislation, as Senate and House GOP leaders race to merge their separate bills into something both chambers can pass on a party-line vote this month.
But provider, insurer and patient advocacy groups doubt they can convince Republicans to remove or soften the provisions they find most objectionable. They say GOP leaders are moving too fast and providing too little opportunity for healthcare stakeholders to provide input.
“It’s a madhouse,” said Julius Hobson, a veteran healthcare lobbyist with the Polsinelli law firm. “What you worry about is this will get done behind closed doors, even before they start the conference committee process.”
One factor that could slow the rush to pass the Tax Cuts and Jobs Act is the need to pass a continuing resolution this week to fund the federal government and prevent a shutdown. Unlike with the tax bill, Republicans need Democratic support for that, and it’s not clear they’ll make the concessions Democrats are demanding.
If the ACA’s insurance mandate is repealed, “our plans will have to evaluate whether they can stay in the individual market or not based on what it does to enrollment and the risk profile of people who choose to stay,” said Margaret Murray, CEO of the Association for Community Affiliated Plans, which represents safety net insurers.
AARP and other consumer lobbying groups are fighting to save the household deduction for high healthcare costs, which the House version of the Tax Cuts and Jobs Act would abolish.
Healthcare lobbyists also are warning lawmakers that capping or ending the federal tax deduction for state and local taxes will force many states to cut Medicaid. Beyond that, they say slashing taxes and increasing the federal deficit will trigger immediate Medicare budget sequestration cuts that would hurt providers and patients, particularly in rural and low-income areas.
“One in three rural hospitals are at financial risk of closure, and sequestration would be devastating for them,” said Maggie Elehwany, vice president of government affairs for the National Rural Health Association. “I’d love to say our message is getting through. But Congress is completely tone-deaf on how troubling the situation in rural America is.”
Hospital groups, led by the American Hospital Association, are battling to preserve tax-exempt bond financing for not-for-profit organizations, which the House bill would zero out. While the Senate bill would keep the tax exemption for interest income on new municipal private activity bonds, both the Senate and House bills would prohibit advance re-funding of prior tax-exempt bond issues.
Hospitals say ending or limiting tax-exempt bond financing would jack up their borrowing costs and hurt their ability to make capital improvements, particularly for smaller and midsize hospital systems. The Wisconsin Hospital Association projected that ending tax-exempt bond financing would increase financing costs by about 25% every year.
According to Merritt Research Services, outstanding end-of-year hospital debt totaled nearly $301 billion in long-term bonds and nearly $21 billion in short-term debt. Nearly all of that debt was issued as tax-exempt bonds.
Suggesting a possible compromise, Rep. Kevin Brady (R-Texas), chairman of the House Ways and Means Committee, said Tuesday that he saw “a good path going forward” to preserve tax-exempt private activity bonds “that help build and enhance the national infrastructure.”
But Hobson raised questions about Brady’s comments. “What is his definition of infrastructure?” he asked. “It suggests they may move away from a blanket repeal, but it doesn’t tell me where they’re going.”
If Republicans decided not to repeal the tax exemption for municipal bond interest income, however, they would have to scale back some of their pet tax cuts for corporations and wealthy families, even as they feel pressure to ease unpopular provisions such as ending the deductibility of state and local taxes. That could make it hard for hospital lobbyists to gain traction on this issue.
“There are a lot of giveaways in the bills that don’t leave a lot of room to recoup the money you lose,” Hobson said.
Some lobbyists hold out a faint hope that the Republicans’ tax cut effort could collapse as a result of intra-party differences, as did their drive to repeal and replace the Affordable Care Act.
One possibility is that Maine Sen. Susan Collins flips and votes no on the tax cut bill emerging from the conference committee if congressional Republicans fail to pass two bipartisan bills she favors to stabilize the individual insurance market.
Collins said she’s received strong assurances from Senate Majority Leader Mitch McConnell and President Donald Trump that they will support the bills to restore the ACA’s cost-sharing reduction payments to insurers and establish a new federal reinsurance program that would lower premiums.
But the fate of those bills is in doubt, given that House Speaker Paul Ryan (R-Wis.) was noncommittal this week, while House ultraconservatives have come out strongly against them.
Collins conceivably could be joined by Alaska Sen. Lisa Murkowski, who also said she wants to see the market stabilization bills passed. If Tennessee Sen. Bob Corker, who voted no on the tax cut bill over deficit concerns, remains opposed, those three GOP senators could sink the tax bill.
“We’d all like to see Collins pull her vote,” Hobson said. “It was always clear that the deal she cut with McConnell won’t fly on the House side.”
One healthcare lobbyist who didn’t want to be named said there may be a deal in the works for House conservatives to support market-stabilization legislation in exchange for lifting budget sequestration caps on military spending.
But healthcare lobbyists are not holding their breath on winning major changes or seeing the tax bill collapse.
“There are chances they won’t reach a deal,” said Robert Atlas, president of EBG Advisors, which is affiliated with the healthcare law firm Epstein Becker Green. “By the same token, Republicans are so determined to pass something that they might just come together.”
House conservatives thumb their nose at the Maine moderate’s bid to slow the demise of the health law.
Sen. Susan Collins is barreling toward yet another health care showdown with her own party. But this time, she might not have the leverage to get what she wants.
Republicans who watched Collins lead the rebellion over the GOP’s Obamacare repeal effort just three months ago are playing tough on yet another high-stakes bill, wagering they can do without the Maine moderate’s swing vote and still claim a narrow year-end legislative win on tax reform.
Collins went along with the tax bill that repeals Obamacare’s individual mandate after Senate Majority Leader Mitch McConnell pledged to pass a pair of bills propping up Obamacare’s shaky insurance markets, including a bipartisan deal resuming payments on key subsidies that President Donald Trump halted in October.
But Speaker Paul Ryan has made clear he’s not bound by the deal, and there’s little urgency among House Republicans to do much of anything on health care before the end of the year. On Thursday, Republican Study Committee Chairman Mark Walker said conservatives received assurances that talks on a spending package to keep the government open won’t address Obamacare.
“The three things we were told are not gonna happen as part of our agreement: no CSRs, no DACA, no debt limit,” he said, referring to efforts to fund Obamacare’s cost-sharing subsidies.
That could cost Collins’ support after she signaled that her vote on the final bill may hinge on the fate of the health care measures.
She told a Maine CBS affiliate Thursday night that she’d wait to see the final language from the conference committee working on the tax bill before committing her vote.
“I won’t make a final decision until I see what that package is,” Collins told CBS WABI 5.
One bill, known as Alexander-Murray, would temporarily restore subsidies to insurers. The second would fund a two-year reinsurance program helping health plans cover particularly expensive patients.
Senate Republicans can only afford two defections and still pass the tax bill using a fast-track procedure that requires a simple majority,with Vice President Mike Pence ready to cast the tie-breaking vote. The margin would become razor thin if Collins holds out, and Sen. Bob Corker maintains his opposition over concerns about the bill’s impact on the deficit.
Yet House Republicans still chafing over the Senate’s failure to repeal Obamacare insist they won’t bend to Collins’ demands. And while Senate Republicans are trying to keep Collins in the fold, there’s little apparent worry so far that her opposition would sink the tax effort.
“I think you guys have to find something else to be concerned about,” said Sen. Tim Scott, one of the 17 GOP lawmakers assigned to merge the House and Senate versions of the tax plan.
Sen. Lamar Alexander, who coauthored Alexander-Murray and has championed its inclusion in a year-end agreement, also waved off the need to pressure House Republicans on the issue.
“The House knows our position,” he said. “When they see that they can lower premiums 18 percent … reduce the debt, reduce the amount of money going to Obamacare subsidies, I think it’ll be a Christmas present they’ll want to give to their constituents.”
One of the few moderates in a Republican conference that narrowly controls the Senate, Collins has regularly used her voice and vote to extract concessions from GOP leaders and ensure she’s a central figure in negotiations.
During the health care debate, she urged the GOP to protect Medicaid and preserve more subsidies for people to buy insurance. When they stuck with their blueprint, Collins joined fellow Republicans Lisa Murkowski and John McCain in a dramatic vote that killed the months-long repeal bid.
And in the run-up to the Senate’s late-night tax vote, she secured three late changes to the bill, including the expansion of a provision allowing people to deduct hefty medical bills that House Republicans had voted to eliminate entirely.
That was on top of McConnell’s “ironclad commitment” to tackle the two health care bills at year’s end — measures that Collins claims will help offset premium increases stemming from the bill’s repeal of Obamacare’s mandate that most Americans be insured.
Collins said Thursday she considers House passage of those Obamacare bills part of that commitment, even though McConnell has only publicly agreed to “supporting passage” of them and can’t singlehandedly force the House to take up legislation.
Ryan hasn’t officially ruled out the possibility, but declined to commit to rolling either of the bills into upcoming spending agreements. Conservatives have loudly opposed any aid for Obamacare, and even moderates who support stabilizing the health law have shrugged at the exact timing.
“What the vehicle is to get it through the system, in the House and the Senate to the president’s desk, I’ll leave that to our leadership,” said Rep. Tom Reed, who co-chairs the bipartisan Problem Solvers Caucus.
Collins insists she’staking the long view, claiming progress Thursday on trying to win over House Republicans during rounds of private negotiations.
“I remain confident, despite your skepticism, that we will eventually get that,” she said.
And as the GOP learned during the repeal debate, the whip count could shift suddenly. Sens. Jeff Flake and Ron Johnson remain wild cards, and either could conceivably join Corker and Collins in torpedoing the tax bill if they dislike the final version.
For now though, Republican leaders are signaling once again that Collins may not get everything she wants on health care — and gambling it won’t cost them a second time.
“I think that these are separate issues,” said Sen. David Perdue. “I’m hopeful that that won’t derail this [tax bill]. We’ve got to get it this done and get it on the president’s desk.”
Two short months after they appeared to move past their campaign to dismantle the Affordable Care Act (ACA), Senate Republicans passed a tax reform package that includes a repeal of the law’s individual health insurance mandate. House Republicans have indicated they will follow suit.
The mandate is an easy target. Since before the ACA was passed, it has been portrayed as un-American. President Trump articulated this criticism during his inaugural address to Congress, when he argued that “mandating that every American buy government-approved health care was never the right solution for our country.” It has also been labeled anti–free market, and it has been called an affront to personal freedom.
It is none of these things.
An individual mandate to purchase health insurance was first proposed in the U.S. by the conservative Heritage Foundation, which in 1989 saw it as a way of creating healthy insurance pools, a solution to what they saw as the “free-rider” problem in health care, and as an alternative to a single-payer system. It was first passed into law by Mitt Romney, the Republican governor of Massachusetts, who promoted it as a market-based idea grounded in the principle of individual responsibility.
Does the individual mandate restrict freedom? Yes, but not unreasonably, and it isn’t unique in this regard. The 49 state laws requiring drivers to carry auto insurance also restrict individual freedoms, as do fishing licenses and nearly all taxes. In the case of compulsory auto insurance, every state except New Hampshire has made the calculation that the harm of curtailing freedom is outweighed by associated goods — for compulsory auto insurance this is the sense of security one gets from knowing that if a faulty driver hits you he or she will have the means to pay your medical bills or repair your car. When one turns to health insurance, the associated goods are much more profound.
The benefit of the individual insurance mandate derives from the collective goods we all receive from increased participation in insurance markets — these include lower rates of uncompensated care, healthier insurance markets, and ultimately lower premiums and better access to health care.. It helps makes the ACA marketplaces sustainable, thereby giving millions a source of comprehensive health insurance, and millions more the peace of mind knowing that they have a place to go if they ever need to buy it. For these last reasons, the individual mandate actually enhances freedom. Having universally available, high-quality health insurance frees us from the fear of being one illness away from financial ruin, from being tethered to a job (or relationship) because it is the only means of coverage, and frees us and our loved ones from the physically or financially disabling effects of an unmanaged illness.
Repealing the individual mandate and the destabilizing of health insurance markets that will follow will harm a lot of Americans. The Congressional Budget Office projects that 13 million people will lose their health insurance because of the repeal.
Nonetheless, Republicans appear poised to move ahead. Crippling the marketplaces hasn’t garnered the ire of key Republican governors who weighed in strongly on the large Medicaid cuts proposed as part of earlier repeal bills. And senators who may have been concerned about the consequences of repeal cared more about passing tax reform — a must-have political victory for Republicans.
The other reason why this newest attack on the ACA may be more successful than earlier ones is that, from the outset, the individual mandate has never had strong public support; it polls lower than other key provisions and has been the target of a disproportionate share of the harsh rhetoric aimed at the law. The Obama administration was never able to sell the public on the connection between a strong mandate and high-quality, affordable health insurance, so for some it has felt like pointless government intrusion.
Regardless of how people feel about the mandate, the facts are clear: millions of Americans have benefited from it and live more freely because of it. Congress should remove the individual mandate repeal from the tax bill to help ensure that 13 million people don’t lose the freedoms it has given them.
Senate GOP leaders won a key swing vote for their tax bill by pledging to pass bipartisan legislation to shore up the Affordable Care Act. But now it looks like those measures’ chances of becoming law are getting dimmer.
Sen. Susan Collins, R-Maine, wants two bills to pass that she hopes will mitigate the effects of a provision in the tax bill that repeals the individual mandate: the Alexander-Murray bill, which would fund cost-sharing reduction payments for two years, and a bill she co-authored with Democrat Bill Nelson, which provides funding for states to establish invisible high-risk pool or reinsurance programs.
Collins voted for the Senate’s version of the tax bill—a critical win for GOP leaders, as they could only lose two votes and it failed to gain her support for previous ACA repeal bills. But she only did so after Senate Majority Leader Mitch McConnell assured her the two ACA stabilization measures would pass.
Yet while some lawmakers previously said those measures could be tacked on to the short-term spending bill Congress aims to pass this week, congressional aides now say it isn’t likely to be included, according to The Wall Street Journal. Further, while House conservatives have indicated strong support for repealing the individual mandate in the final version of the GOP tax bill, they are far from on board with the two ACA stabilization bills.
For example, Ohio Rep. Warren Davidson said he’s a “hard, hard, very hard no,” on the Alexander-Murray bill, per the WSJ article.
House Speaker Paul Ryan could also be a barrier to passing the two bills. His office told a meeting of congressional leadership offices on Monday that he wasn’t part of any deal between Collins and McConnell, The Hill reported. But his office didn’t say outright that it opposed the bills.
For her part, Collins said it will be “very problematic” if the ACA stabilization bills don’t pass, according to the WSJ. She also won’t commit to voting for the final version of the tax bill until she sees what comes out of a conference committee between the House and Senate.
Even if those measures do pass, there have been questions about whether they would do enough to soften the blow of repealing the individual mandate. The Congressional Budget Office has advised that the Alexander-Murray bill would do little to change its prediction that repealing the mandate would increase the uninsured rate and raise premiums.
A new analysis from Avalere found that Collins’ bill could help stabilize the individual market by increasing enrollment and reducing premiums in 2019, but the consulting firm’s experts cautioned that those effects could be overshadowed by repealing the individual mandate.
Reproduced from Kaiser Family Foundation Health Tracking Poll, Nov. 8-13, 2017; Note: Question wording abbreviated, “Don’t know”/”refused” responses not shown; Chart: Axios Visuals
The tax bill that just passed the Senate eliminates the Affordable Care Act’s individual mandate, and the House is likely to go along when Congress writes the final version. With the tax legislation moving so quickly and the mandate lost in the maze of so many other consequential provisions, we are not likely to have much public debate about this big change in health policy.
Why it matters: If we did, even though the mandate has never been popular, our polling shows that the public does not necessarily want to eliminate it as part of tax reform legislation, once they understand how it works and what the consequences of eliminating it might be.
The back story: Republicans have targeted the ACA mandate because they want the $318 billion in savings the Congressional Budget Office says they would get to help them pay for their tax cuts. (The change would save money because fewer people would get federal subsidies on the ACA marketplaces or apply for Medicaid coverage.)
They have also targeted the mandate because they think it’s so unpopular. Our polls have consistently shown that the mandate is the least popular element of the ACA and in the abstract, more Americans (55%) would eliminate the mandate than keep it (42%).
Yes, but: When people know how the mandate actually works, and are told what experts believe is likely to happen if it’s eliminated, most Americans oppose repealing it in the tax plan.
When people learn that they will not be affected by the mandate if they already get insurance from their employer or from Medicare or Medicaid, 62% oppose eliminating it.
When people are told that eliminating the mandate would increase premiums for people who buy their own coverage, as the CBO says it will, they also flip, with 60% opposing eliminating the mandate.
And when they’re told that 13 million fewer people will have health coverage – another CBO projection – 59% oppose eliminating the mandate.
The bottom line: Many people change their minds when they learn more about facts and consequences, which happens as the lights shine brighter on them in legislative debates. This happened to the “skinny repeal” proposal, and it would happen to single payer.
But as the tax legislation rushes through Congress and heads to the final negotiations, there is almost no chance for the public to grasp the tradeoffs that would come from eliminating the mandate and who is affected and who is not. If they did, the polling suggests, eliminating the mandate might prove far less popular than Republicans seem to think it is.
HENRY KOTULA 