“After six long years of fighting, working and waiting, today we begin the repeal of Obamacare,” House Ways and Means Committee Chairman Kevin Brady (R-Texas) said in Reuters. Instead of rejoicing, a conservative revolt has already begun against the newly unveiled Republican health care plan, the American Health Care Act.
A clue to the problems that Republicans such as Rand Paul (R-Ky.) and Tom Cotton (R-Ark.) have with the new bill can be seen in its first paragraph. Although the bill’s title refers to “repeal and replace” of the Affordable Care Act, the actual text of the bill states that “the Patient Protection and Affordable Care Act… is amended….”
Although the Republican bill does eliminate the Obamacare mandate, many provisions of the act are left intact. Margot Sanger-Katz writes in the New York Times that the Obamacare rules mandating acceptance of customers with pre-existing conditions, unlimited lifetime caps on insurance payouts, and limits on how much customers can be charged for copayments and deductibles remain unchanged. Additionally, the GOP plan keeps the Obamacare requirement that all plans cover 10 categories of benefits without a copayment, as well as including rehabilitation and maternity care. The Republican plan also would allow children to stay on their parents’ policies up to age 26.
Even though the Obamacare mandate is eliminated, the Republican solution does have a similar penalty. Under the GOP plan, people who drop their insurance and then restart it would pay a surcharge of up to 30 percent.
A major sticking point for many conservatives is how the Republican plan replaces the Obamacare subsidies with refundable tax credits. Obamacare’s subsides were based on income, but the Republican plan’s tax credits are based on age. The rationale is that insurance is more expensive for older people. The final version of the bill did cap the income for these tax credits at $75,000 for individuals and $100,000 for married couples. Critics of the tax credits call them a new entitlement.
A second major point of disagreement among Republicans is Obamacare’s Medicaid expansion. According to the Washington Times, the Republican plan preserves the Medicaid expansion and its federal funding through Jan. 1, 2020.
Four Senate Republicans had pledged to vote against any bill that does not slowly phase out the Medicaid expansion. “As the largest payer of mental health and substance use services in the United States, it is critical that any health care replacement provide states with a stable transition period and the opportunity to gradually phase in their populations to any new Medicaid financing structure,” Sens. Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Lisa Murkowski of Alaska said in a joint statement.
Some aspects of the bill were more popular with conservatives. NPR points out that the bill would defund Planned Parenthood by prohibiting Medicaid from paying for services at the group’s clinics. The bill would also repeal several Obamacare taxes including the medical device tax and the tax on expensive “Cadillac” health plans. The bill’s refundable tax credits could not be used for plans that cover abortion.
The bill, which is already being called “TrumpCare” and “SwampCare” by opponents, faces an uphill battle for passage. Several members of the Freedom Caucus have already voiced opposition. “Right now the Speaker of the House does not have the votes to pass this bill unless he’s got substantial Democratic support,” Rep. Mo Brooks (R-Ala.) told The Hill.
Assuming no Democrats crossover to vote for the bill, only 22 Republicans can defect and vote against the bill and it still pass. The Freedom Caucus has 40 members.
Things look even worse in the Senate. Republicans only hold a two-vote advantage over Democrats. In addition to the four Republican senators protesting the eventual end of the Medicaid expansion, at least three others have expressed opposition to the bill. Rand Paul and Tom Cotton were joined by Utah Sen. Mike Lee in arguing against the bill that Paul called “Obamacare lite.”
“We don’t know how many people would use this new tax credit, we don’t know how much it will cost, and we don’t know if this bill will make healthcare more affordable for Americans,” Sen. Lee said in a statement. “This is exactly the type of backroom dealing and rushed process that we criticized Democrats for.” Due to last minute changes, the cost of the bill has not been scored by the Congressional Budget Office, the Wall Street Journal reported.
Republican opponents of the bill plan to introduce their own repeal legislation. “We think you have to get rid of Obamacare completely, so tomorrow I will introduce the bill that every single Republican voted on just 15 months ago, the bill that actually repeals Obamacare,” Rep. Jim Jordan (R-Ohio) said in Business Insider.
On the other hand, the Trump White House seems happy with the American Health Care Act. “We’re going to do something that’s great. And I am proud to support the replacement plan released by the House of Representatives,” President Trump, who supported universal health care as recently as January, said. “It follows the guidelines I laid out in my congressional address. … This will be a plan where you can choose your doctor and this will be a plan where you can choose your plan. And you know what the plan is. This is the plan.”