The fight over health care reform is the single most recognizable – and, in many ways, the most important – source of tension between the modern Republican and Democratic parties. Passing the Affordable Care Act (“ACA”) in 2010 was a monumental legislative achievement for Democrats. The ACA upended the health care status quo in pursuit of comprehensive reform, something that had been politically unattainable for decades. For their actions, Democrats paid a huge electoral cost. “Repeal and replace” became the endless mantra from Republican lawmakers, and the public quickly soured over the law. Feeding off that public skepticism, Republicans were propelled to huge electoral gains, in election after election after election.
Of the two parts of the mantra, Republicans have had the easiest time with “repeal.” Since 2010, Republicans have cast 67 votes to repeal, defund, or dismantle the ACA, with the latest attempt occurring last Tuesday. Republicans have never, however, attempted to “replace” the ACA. Sure, they have offered a wide array of proposals. But Republicans have never made an actual effort to pass replacement legislation. Perhaps this inaction can be interpreted as a consequence of circumstance. As Jamelle Bouie wrote in Slate, “House Republicans could have crafted a bill to replace Obamacare, but then they would have had to make the compromises and pay the costs of building an alternative without the benefit of bringing it into law – as soon as any bill reached the Senate, Democrats would have killed it.”
Now that Republicans control all of Congress, however, they finally have the opportunity to replace the ACA if they want to without the threat of Democratic obstructionism. Last Wednesday, three Senate Republicans took a step in that direction.
On February 4, Sens. Orrin Hatch (R-UT), Richard Burr (R-NC), and Fred Upton (R-MI) unveiled their blueprint for Republican health reform, called the Patient Choice, Affordability, Responsibility and Empowerment (CARE) Act. According to its synopsis, the CARE Act would, among other things:
- Ensure no one can be denied coverage based on their pre-existing condition;
- Prohibit insurance companies from imposing lifetime limits on a consumer;
- Adopt an age rating ratio that limits the amount an older individual will pay to no more than five times what a younger individual pays (5 to 1) as a baseline, unless a state affirmatively elects to have a different ratio;
- Require health plans to offer dependent coverage up to age 26, unless a state opts out of this provision;
- Individuals with an annual income up to 300% of the Federal Poverty Level (FPL) would be eligible to receive an age-adjusted, advanceable, refundable tax credit to buy coverage;
- States would continue to receive taxpayer-provided pass-through health care grants for pregnant women, low-income children, and low-income families, with funding based on the number of low-income individuals at or below 100% of the FPL;
These proposals should sound familiar. The most recent iteration of the CARE Act, in fact, is virtually identical to an outline released last year by Hatch, Burr, and now-retired Sen. Tom Coburn (R-OK). In addition, it is eerily similar to the ACA alternative that former presidential candidate Mitt Romney proposed in 2012, as well as the GOP House alternative offered in the midst of the 2009 legislative battle. In other words, the CARE Act is mostly a rehash of past Republican health care prescriptions – prescriptions which, it should be noted, have failed to gain broad Republican support.
That fact is not that surprising. But what is interesting is just how remarkably similar the CARE Act is to the act it is meant to replace. Prohibit insurers from denying coverage based on pre-existing conditions? Yes, but with an important caveat (more on this below). No lifetime limits on coverage? Check. Government set limit on how much insurers could vary premiums by age? In there, but the ratio would be expanded from 3-1 up to 5-1. Young people up to age 26 can stay on their parents’ plan? Yes, but a state could opt out. Subsidies for middle-class people? Yes, but just up to 300 percent of the FPL (the ACA has a 400 percent threshold). Coverage for the poor? Yes, but just up to 100 percent of the FPL (the ACA has a 138 percent threshold).
Essentially, Hatch, Burr, and Upton went through the ACA, isolated many of its most popular principles and provisions, and said, “Let’s do that, just a little less generously.” The CARE Act, in other words, is little more than “Obamacare Lite.” In Philip Klein’s book Overcoming Obamacare, Michael Cannon scolds the right for such proposals, which he blames for Republicans getting outplayed, again and again, on health care.
Conservatives are falling into the same trap now that they fell into the fighting with the Clinton health plan . . . [T]hey’re conceding the left’s premises that the government should be trying to provide everybody with health insurance, or the government should be trying to expand access to health insurance, or the government should be subsidizing health insurance, because some people need help and therefore the federal government should be the one to help them. The problem [comes] because once you accept those premises, all of your solutions look like the left’s solutions. They look like Obamacare.
The similarities between the ACA and the CARE Act quickly dissipate, however. When it comes to the CARE Act, the devil is in the details. To almost everyone on Capitol Hill, health reform means insuring the uninsured. And at its core, the CARE Act is yet another reminder that Republicans have no interest in health care reform that significantly increases access to care. The CARE Act erases the ACA’s coverage requirements for individuals and employers. It eliminates the state and HealthCare.gov federal insurance marketplaces. It ends the Medicaid expansion, replacing it with an allotment based on the number of poor in each state. And it brings back medical underwriting, despite its attempt to convince you that that’s not what it does.
That last point is perhaps the most important difference between the ACA and the CARE Act, not necessarily because of the change in policy, but because of what it reveals about its drafters.
Under the ACA, insurance companies cannot deny you coverage because of a pre-existing condition. Ever. The CARE Act is presented as though it does the same thing. In fact, the phrase “ensure no one can be denied coverage based on their pre-existing condition” is the one sentence in the entire synopsis that is italicized. But that’s not quite true. Under the bill, insurers could still turn away people with pre-existing conditions. The only exception is if you have “continuous coverage” – that is, you’re either already insured or have been able to maintain some form of insurance despite losing the coverage you had through your employer. For the uninsured, the CARE Act envisions a one-time open enrollment period; if you’re uninsured and don’t get coverage during that time, however, you’re out of luck. That is a very different thing from the ACA’s guarantee.
The fact that the CARE Act attempts to convince you otherwise, however, is revealing. The “ensure no one can be denied coverage based on their pre-existing condition” statement is an empty platitude. It’s nothing more than a sleight of hand, a deception meant to make you believe the proposal does something that it does not. This point is important, because the CARE Act’s approach to pre-existing conditions is representative of the proposals approach to the idea of health reform more broadly. The CARE Act is a desperate attempt by Republicans to convince you that they genuinely and sincerely care about health care reform. But the proposal is a sleight of hand.
The CARE Act is not, as some commentators have suggested, “an impressive new Obamacare replace[ment] plan.” If anything, it’s a signal that some Republicans, at least, have ceded a lot of ground in the broader debate over health care. But even more importantly, it’s a signal that Republicans truly don’t care about real reform.
This is not a shocking revelation. In fact, it should be obvious if you’ve been paying attention to Republican rhetoric about health care for the past few decades. Republicans opposed Medicare. They opposed CHIP. They’ve opposed every expansion of Medicaid. And they’ve opposed every attempt to pass universal healthcare legislation in the last century. The reason why the CARE Act looks so much like the reform it aims to replace is not mere coincidence. It looks that way because Republicans have no interest in a plan of their own.
Five years after John Boehner promised to repeal the ACA and “enact real reforms that will lower health care costs and help small business get back to creating jobs,” Republicans still haven’t come up with a credible alternative. Why? Republicans were fine with the old system, the one that permitted insurance companies to deny you coverage if you have a pre-existing condition, drop your coverage when you become sick, and charge you more for insurance if you’re a woman than if you’re a man. To many Republicans, these are acceptable costs. Because “free market,” or whatever.
If Republicans were serious about health care reform, they would actually build a health care plan the party can agree to, and not just talk about one. But the fact of the matter is that Republican health care plans only exist if there is no chance of them being implemented. Reducing health care costs and increasing access to health care just isn’t a priority for today’s Republican Party. The “replace” part of “repeal and replace” has always been a fraud. It’s time to stop believing otherwise.