An analysis of the Republican alternative to Obamacare

The Republicans have an alternative to Obamacare and they may have given the Democrats a big political gift.

The proposal was unveiled by Republican Senators Richard Burr (NC), Tom Coburn (OK), and Orrin Hatch (UT).

The Republican plan targets many of the most unpopular parts of the Affordable Care Act such as expensive mandated benefits and the resulting lack of choice, the individual mandate, the employer mandate, and age-rating disruptions.

My sense is that most independent voters — the ones that matter in an election year — don’t want Obamacare repealed; they want it fixed.

The problem for Republicans is that they have such a visceral response to the term “Obamacare” that they just can’t bring themselves to fix it. The notion that Obamacare might be fixed and allowed to continue as part of an Obama legacy and as a Democratic accomplishment is something they can’t get past.

So, the only way Republicans can propose an alternative to Obamacare is to first wipe the health insurance reform slate clean and start over.

There is a problem with that strategy. Have you heard the one about, “If you like your health insurance you can keep it?”

It is now 2014. The Affordable Care Act is law. The Republican alternative would mean taking lots of things away the Democrats will quickly pounce on:

Medicaid expansion. The Republican alternative would “not expand” Medicaid — presumably rolling back the Medicaid expansion in each of the 24 states that have expanded it. By year-end, millions of Americans will have gained coverage. Who wants to tell these people now on Medicaid the Republican alternative only contemplates covering pregnant women, low-income children, and low-income families at the old levels? Twenty-four states that would see benefit cuts equates to 48 U.S. Senators.

Insurance subsidies. The Republican alternative would offer health insurance premium subsidies for people up to 300% of the poverty level. Far fewer people than expected are buying Obamacare but that number will be well into the millions before long. Obamacare offers subsidies up to 400% of the poverty level meaning that lots of people would lose their subsidies — and they would be the voters who are solidly middle class.

The tax exclusion for employer-based health insurance. There is no health insurance policy so sacred in America as the one a worker gets from their employer. The Republican alternative would cap the tax exclusion, currently at 100% of whatever the employer gives the worker and their family for health insurance, at 65% of the cost of the “average” cost of a policy. Democrats will quickly jump on this as a huge middle class tax increase and an attempt to undermine employer-based health insurance.

Lower premiums for older people. A controversial part of Obamacare was its requirement that older people can’t be charged more than three times the premium of the youngest. That contributed to the rate shock that hit many people in the small group and individual market when Obamacare policies had to comply. Republicans would take people through the same political nightmare once again but in reverse this time. Their plan would cap rating differences at 5:1, thereby forcing older peoples’ premiums up, and younger peoples’ premiums down. Older people tend to vote more often. Ironically, they have also been the ones who so far have more often bought an Obamacare compliant policy.

The prohibition of pre-existing condition provisions. As of January 1, 2014, there is no such thing in America any longer. But Republicans would bring the provision back if people did not maintain continuous coverage. That sounds fair. But what happens when someone is forced to drop their expensive coverage when they lose their job for a few months and the Republican tax credits don’t give them enough help maintaining it? Democrats will be able to think of lots of scenarios where a family playing by the rules has no choice but to drop coverage and face pre-existing condition provisions once again.

Each of these Republican proposals is credible and constructive and should be part of any discussion over how to move forward with health insurance reform.

No one has been more critical than me, for example, toward Democrats who refused to phase-in age rating compression rather than shock the market all in one year. But, it’s done. Rolling key provisions of the Affordable Care Act back would only create a new set of offended parties who would want to keep the insurance they have.

This sets up an incredible political irony.

By not being willing to fix Obamacare, the Republicans have put themselves in the position of having to take things away from people — many of them from solid middle class people.

That opens up a huge political opportunity for the Democrats.

Democrats can now claim the high political ground by admitting they made mistakes and they are now willing to fix the things that are so obviously wrong with Obamacare. They no longer have to defend it. They become the, “Don’t throw the baby out with the bathwater,” team. Democrats can now be critical about the most unpopular parts of Obamacare because they are the ones willing to fix them!

It is now the Republicans, the Democrats will argue, who would put the country through another round of health insurance disruption.

Of course, Republicans will claim that Obamacare can’t be fixed.

But tell that to the older people who Democrats will be quick to remind will be paying more, the middle class people who would get their health insurance subsidies cut, and the 160 million people who get their health insurance — which they really like — through employer-based plans and will see their taxes go up.

I am convinced Obamacare will have to be fixed. It is a mess as it is.

But it will limp along for at least a few years; the health plan “reinsurance” provisions of the Affordable Care Act will assure that.

Even if the Republicans win the Senate this fall, as long as Barack Obama is in the White House there will not be a repeal of Obamacare.

The first real crack the Republicans will have at repealing and replacing Obamacare would be in 2017 — ifthey sweep the Congress and the White House in 2016. By then this law will be even more entrenched.

I doubt Republicans will ever have the 60 Senate votes they would need for a unilateral remaking of Obamacare. That means any fix will have to come from a bipartisan agreement at some level. A bipartisan agreement would give both sides the political cover they would need for the controversial but fundamental improvements Obamacare needs.

I really believe we will ultimately see a bipartisan agreement to fix Obamacare — most likely after the 2016 elections — that ironically could well include many of the things these Republicans are talking about like caps on health plan tax exclusions, an alternative to the individual mandate, far more flexibility in plan choices, more Medicaid flexibility and accountability for states, and maybe even real medical malpractice reform built upon ideas like “health courts.”

But by putting a repeal and replace plan on the table, rather than focusing on a fix from the point we are at today that creates obvious losers, Republicans may have handed the Democrats a big political gift.

I can’t disagree with those who argue that all sides have a responsibility to tell us what they would do.

But I will suggest the Republicans would have been better off starting from the place we are at in 2014. About the only thing they will now end up doing is wasting some good ideas.

Robert Laszewski is president, Health Policy and Strategy Associates and blogs at Health Care Policy and Marketplace Review.

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  • John C. Key MD

    The solution is repeal and replace, with a whole lot of emphasis on “Repeal”. The factors that you list as making ACA bulletproof are primarily its poison pills as well. The Medicaid expansion is a farce; insurance subsidies are merely redistributionist cost-shifting; lower premiums for the elderly are one of the things that has us messed up now (i.e, Medicare). Portability, interstate purchases, and preexisting conditions are relatively easy to legislate but can’t be treated as “free”.

    I was an early and naive supporter of single payer, but the present monstrosity should convince anyone that the only way to go is to tear off the page and start over with a less ambitious, more feasible, incremental approach.

    The second best option is “Repeal and Don’t Replace”. We would be better off than we are now.

  • ninguem

    “Private practice is going the way of the dodo bird.”

    The private practice of medicine exists in both the Canadian system and the National Health Service.

  • Bradford Lacy

    Every bill comes with its own set of unintended consequences. I believe the President likely new about some of the unintended consequences of the ACA but chose to press on thinking he was doing what is best for our country. The Republicans who wrote this bill also probably know about the unintended consequences of their bill and will try to keep them concealed at least until after the election this fall. It is not yet clear which bill is better although I think it may be more disruptive to repeal and replace. I do however disagree that “status quo” is the best option. There are a lot of people who have been denied health insurance because of a pre-existing condition or have ran out of insurance because of a plan year maximum who likely concur.

  • dontdoitagain

    Still chasing the rabbit of determining who should pay and how much I see. The root of the problem is the expense of medical care. Until that problem is tackled, and it can be, this whole discussion is moot. The problem is so simple…health care is too expensive. Where is this being addressed?

  • Dorothygreen

    There is another option to the Canadian or British model. Check out Switzerland. There is affordability, negotiations with the major players at the fed level, NO private insurance for basic services – same rate for all and then supplemental for those who want and can afford. At least 70% of the country could afford and have choice. No Medicaid – the gov supplements insurance. Lots more that makes sense. Expensive but half of US costs.

    “The other party” has, through the AMA, obstructed universal health care for 100 years. Then hospitals, insurance plus pharma, equipment and labs, still have lobbies that keep their profits high at the expense of income tax payers and individuals.

    Some states are working toward such a model – Vermont and probably Hawaii. Maybe they will set the stage for the rest of the country. But even this will not solve the problem of high costs. It must be done at the Federal level.

    I think you are wrong about the “other side” – as long as “citizens united” decision stays in place and we do not have campaign reform,our government will continue to be owned by Corp Am inclusive of the Medical Profit Machine – “the other people” of “we the people”. Money talks – we need over 100 million voices to drown them out.