First, the good news: Dr. Paul Ryan just operated to remove the Obamacare cancer that has made America sick for nearly seven years.
The bad news: Dr. Ryan removed half the tumor and then stitched the patient shut.
The Obamacare measure unveiled Monday needs radical surgery if it ever will repeal and replace this disastrous program. Voters sent President Donald J. Trump and a Republican Congress to Washington to repeal Obamacare — every malignant cell of it. And that’s where the GOP needs to start.
Repealing Obamacare is easy. Republicans already did it.
Every GOP senator except Illinois’s Mark Kirk voted for H.R. 3762, the Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015. This full-repeal bill passed the Senate 52–47 that December. The House approved the measure the next month, 240–181, with 239 Republican yeas and only three GOP nays.
Obama rejected this measure, alas, and then Congress failed to override his veto.
“As Republicans, we decried the fact that Obama would veto it,” Representative Mark Sanford (R., S.C.) told journalists Tuesday. “Why would we now water down this same bill and send a new and weaker bill to President Trump?”
Representative Jim Jordan (R., Ohio) is equally mystified:
We put on President Obama’s desk a bill that repealed Obamacare, got rid of every single tax, got rid of the mandates, and now the first thing Republicans are bringing forward is a piece of legislation that we’re going to put on a Republican president’s desk that says we repeal it but keeps Medicaid expansion and actually expands it, that keeps some of the tax increases. That is not what we promised the American people we were going to do.
This bill would broaden Health Savings Accounts (HSAs) and scrap most benefit mandates, such as the baffling requirement that childless policy holders purchase pediatric vision and dental insurance to cover their offspring who do not exist.
According to Grover Norquist of Americans for Tax Reform, “the Obamacare repeal bill abolishes 14 taxes that today siphon off nearly one trillion dollars from American taxpayers each decade.” That’s good news, although these taxes remain until next January 1.
Too bad the so-called Cadillac tax on gold-plated health plans is delayed until 2025 rather than junked today. Ryan’s plan also eliminates the individual mandate, although critics say it converts Obamacare’s fines from penalties levied by government into penalties collected by insurers.
“The GOP plan tosses insurance companies a gift, offering them a subsidy for covering sick and expensive patients,” Cato Institute scholar Michael Tanner complained Wednesday at NRO. “This provision looks a lot like Obamacare’s insurer bailout, which Republicans, led by Marco Rubio, took such pride in killing.”
Health-policy analysts also lament that the preexisting-illness-coverage mandate remains, rather than more market-oriented high-risk pools. This would leave GOP fingerprints all over Obama’s unwieldy regulation.
“Ryancare” forgoes tax credits offered directly to individuals and families, which would cut their taxes and help them shop for coverage. Instead, expenditures — disguised as “tax credits” — would go directly to insurance companies. These age-adjusted payments would hit $9,000 for a typical family of four with parents in their early 30s. That’s more than double the analogous $4,200 credit proposed by Health Secretary Tom Price, M.D., when he was a Georgia congressman.
Missing: Price’s one-time, $1,000 tax credit for opening each HSA, a powerful incentive to proliferate such pro-market financial vehicles.
Given these multiple shortcomings, Republicans should thank Ryan for his opening bid and, instead, re-adopt H.R. 3762, which attracted virtually unanimous Republican support just 14 months ago. There is no reason to send President Trump a bill that is to the left of what Republicans handed Obama. “Clean repeal,” as Senator Rand Paul (R., Ky.) calls it, unites Republicans. So, dispatch H.R. 3762 version 2.0 to the White House and let President Trump add Obamacare repeal to his list of promises kept.
Republicans then must move immediately to replace Obamacare. Here, too, they need to do far better, with Ryan’s legislation serving as no more than a rough draft.
The House leadership bill is, at best, tepid. This measure’s name confirms its inadequacy. The American Health Care Act. ZZZZZZzzzzzzzzzzz.
Why not the Health Care Freedom Act? This at least would suggest that free markets and patient choice were among the bill’s key ingredients.
Even the grotesquely misnamed Affordable Care Act reputedly aspired to lower costs, an objective on which it foundered — big league. But, at least, that goal sailed from its mast.
Sadly, the American Health Care Act dreams merely of being more than Mexican, but not quite Canadian.
Republicans are split badly: Legislation by senators Susan Collins of Maine and Bill Cassidy of Louisiana would give Obamacare a manicure rather than an operation. Ryancare is somewhere in the middle, containing both good and bad elements. On the right, the House Freedom Caucus and Senators Ted Cruz of Texas, Mike Lee of Utah, Ron Paul of Kentucky, and Marco Rubio of Florida consider Ryancare bad medicine and correctly demand something far more worthy of conservative support.
Unable to unite behind one replacement plan, congressional Republicans resemble a large family that cannot decide which prix fixe menu to order for dinner. Some don’t like steak. Others don’t care for salmon. The vegetarians want neither. And nobody wants the cauliflower side dish that accompanies each entrée.
So, at an impasse on choosing a single menu, Republicans should opt for the buffet. Steak lovers will get their sirloin with no salmon. And vice versa. The vegetarians will avoid both. And the steamed cauliflower will go cold in peace.
The better way to replace Obamacare is to have many, many votes — each on a different aspect of replacement.
In legislative rather than culinary terms, the way to do this is to avoid having one giant replacement bill, which Democrats will oppose in lock step and Republicans might pass, but only if free-market stalwarts bite hard into wooden spoons as they vote.
The better way to replace Obamacare is to have many, many votes — each on a different aspect of replacement.
So, if GOP congressman Smith really dislikes HSAs, for some strange reason, he can vote against HSAs. Smith likely would vote yes on most everything else. If Senator Jones dislikes buying insurance across state lines, she can oppose that while supporting the other repeal questions as they occur.
Likewise, Democrats who would vote 100 percent against an omnibus replacement blob probably would split up, with some Democrats voting for, say, association health plans or the basic concept of letting Americans own, control, and transport their insurance policies. There likely would be at least a few Democratic votes among those needed to adopt most of these individual replacement planks, although many would pass strictly on party lines. Overall, this approach should establish bipartisan majorities for much of a replacement bill, rather than a 2017 GOP yang to the 2010 Democratic yin of single-party Obamacare enactment with zero Republican support.
And if the Democrats vote down each and every idea that comes to the House and Senate floors, that would give Republicans perhaps 20 or 25 different angles from which to hammer them in November 2018. (“Call Senator Heitkamp [D., Neb.] and ask her: ‘Heidi, why won’t you let me have an HSA?’”)
Either way, Republicans win.
And any measure that fails to win a majority of GOP votes probably deserves to lose.
Each of these votes should start in the House, where Republicans enjoy a wider majority within which to navigate. Senate Republicans control a much narrower margin and must endure filibusters and other Democratic roadblocks. As they pass the House, association health plans, price transparency, malpractice reform, longer de facto patent-protection periods for prescription drugs (which would lower prices), and other replacement vehicles would roll in like Ford Mustangs on an assembly line. This will pressure the Senate to finish each separate measure and send it to President Trump for his signature. As he approves one bill after another, this would generate momentum for even more improvements.
This flurry of liberationist activity would unite Republicans, thoroughly or largely, and leave Democrats divided, dazed, and confused. This also would show America’s voters that their unified Republican government is doing precisely what it was elected to do.
Beyond this process, much of replacement lies in the hands of Dr. Price. The text of the (un)Affordable Care Act features the phrase “the Secretary shall” 811 times. This gives Secretary Price enormous latitude to decide that Obamacare “shall” stop doing about 811 different things. This will advance the Trump administration’s underappreciated commitment to robust deregulation.
Also, on the thorny matter of defunding Planned Parenthood, President Trump was highly deft to offer this group a deal: He would continue their federal funding, so long as they stop being an abortion factory. Trump correctly can say that he favors mammograms, pap smears, and other women’s-health procedures 100 percent, but he will not spend taxpayer dollars to kill children. He can repeat this time and again and simply say that he respects Planned Parenthood’s right to choose whether or not to perform abortions, so long as they accept the consequences if they do so. Planned Parenthood, of course, will continue to reject this deal. However, repeating that offer positions Trump as entirely reasonable and not, as the Left would claim, as someone who “couldn’t care less about women’s lives.”
Finally, when Democrats threaten to filibuster against replacement provisions that fall outside filibuster-proof budget-reconciliation procedures (which Democrats deployed to enact Obamacare in 2010), Senate majority leader Mitch McConnell (R., Ky.) should tell Democratic leader Chuck Schumer of New York that merely threatening filibusters will not work. If Democrats really want to filibuster, then they must filibuster.
Thus, McConnell should force Schumer and his Democrats to brew the coffee, roll the cots into the hallways, stand on the Senate floor, and speak until dawn. If Democrats want to talk until their jaws detach in order to prevent Americans from buying insurance across state lines or from depositing their tax credits into HSAs, let them. Democrats will expose themselves as hardened socialists who want to deprive Americans of the freedom to care for themselves and their loved ones unscolded by Washington’s wagging fingers.
McConnell should bring up the most benign and unobjectionable items first. If Schumer and his Democrats filibuster those provisions, they will look as extreme and unreasonable as they really are. As they lose one public-relations skirmish after another, the Party of Nyet’s obstructionism will appear increasingly foolish and destructive. This will give more controversial replacement planks better prospects against embarrassed and exhausted Democrats.