By Amy Goldstein,
Now that Senate Republicans have voted down their own two main plans to overturn much of the Affordable Care Act, many in the Senate GOP are suddenly fastening their hopes onto a “skinny repeal” to keep aloft their goal of tilting federal health policy in conservative directions.
The plan, which popped into view this week, is being portrayed by the chamber’s Republican backers as a modest measure, because it would remove just a few elements of the sprawling 2010 health-care law. Two of those elements, however, lie at the very foundation of the compact the ACA has created among the government, the insurance industry, the nation’s employers and the American public.
The skinny repeal could come to a vote as early as Thursday. For now, it is waiting in the wings, a set of ideas that could be introduced as a bill or as an amendment to existing GOP health-care legislation. A congressional budget analysis Wednesday night forecast that the plan would increase the number of uninsured people by 16 million, and health insurance companies warn that it would drive up rates.
The central features of the skinny repeal would eliminate the ACA’s requirements that most Americans carry health insurance and that employers that have 50 or more workers offer them health benefits.
The skinny idea plays off the fact that the insurance requirements, or mandates, are the most unpopular parts of the current health-care law, based on years of public opinion polling. By focusing mainly on those features, plus the elimination of an ACA tax on medical devices, the political strategy behind this narrow bill would be to court Republican conservatives and centrists alike, adopt the measure and then catapult the passed bill into negotiations with the House, which approved its own anti-ACA legislation this spring. The result: the Republican drive to reshape the health-care system stays alive, buying the Senate’s GOP leaders more time to try to corral their members to agree on a plan that would pass both houses of Congress.
Though it would have few provisions, the skinny plan would have big effects.
In a hasty analysis sought by the Senate’s Democrats, congressional budget analysts are estimating that the changes would leave an additional 1 million Americans uninsured this year, because consumers would immediately become free to drop coverage. The loss of insurance would quickly swell to 15 million in 2018, mainly among people who buy health plans on their own — the kind of coverage sold through the ACA’s marketplaces — or through their jobs.
At the end of the coming decade, 16 million extra people would be uninsured, according to the nonpartisan budget scorekeepers. That is almost three-fourths of the 22 million extra people the analysts predict would be uninsured under the Better Care Reconciliation Act, the much broader Senate Republican bill that would unwind much of the ACA and substitute with new policies. The Senate, including nine Republicans, rejected that bill in a vote on Tuesday night.
Under the skinny version, the largest additional segment of people without coverage in 2026 would be 7 million who otherwise would be on Medicaid, the public insurance program for low-income Americans. That’s even though the skinny plan would not touch Medicaid’s rules or funding. The broader GOP health-care legislation would reduce Medicaid recipients that year by 15 million. That broader bill would abolish the ACA’s expansion and, for the first time in Medicaid’s half-century history, start in a few years to restrict funding for the program as a whole.
For people who buy their own health policies, the skinny plan would cause 5 million fewer Americans to have coverage in a decade — the same as under the broader bill.
The effects that the skinny approach would have on consumers and the business of health care already have drawn scorn from several vantage points.
The left-leaning consumer-health lobby, Families USA, has branded it a “Frankenstein bill” and contended that it could lead to a “bait-and-switch” because it could blossom into more profound health-policy changes in House-Senate conference-committee negotiations.
Health insurers are especially worried. As the ACA was being assembled early in the Obama administration under a Democratic-led Congress, negotiations with the insurance industry were intense. In the end, industry representatives agreed to terms uncomfortable for them — such as a ban on charging more to customers with expensive medical problems, or denying them coverage — in exchange for the law’s promise that most Americans must have health insurance. In that way, industry leaders reasoned, they would gain millions of healthy new patients whose modest medical expenses would balance out the expense of insuring the sick.
Ever since, the ACA’s mandates — or at least strong federal incentives for people to stay insured — have been a bedrock underlying insurers’ willingness to participate in the insurance exchanges, or marketplaces, the law created. On Wednesday, the Blue Cross and Blue Shield Association issued a warning. “A system that allows people to purchase coverage only when they need it drives up costs for everyone,” the association’s statement said.
On Thursday morning, America’s Health Insurance Plans, another main industry trade group, echoed those sentiments in its own statement, which alluded to the skinny idea. It said, “targeted proposals that would eliminate key elements of current law without new stabilizing solutions … will not solve the problems in the individual market and, in fact, will result in higher premiums, fewer choices for consumers and fewer people covered next year.”
Meanwhile a group of 10 governors, including four Republicans, dispatched a letter to Senate Majority Leader Mitch McConnell (R-Ky.) and Minority Leader Charles E. Schumer (D-N.Y.), urging them to jettison the GOP plans, fat or skinny, and begin a bipartisan effort to shore up the ACA’s insurance marketplaces. The signers included the governors of Ohio and Nevada, who have resisted the Senate’s anti-ACA legislation mainly because of the squeeze it would put on Medicaid — but now have joined the opposition to the narrower bill, as well.