Republican efforts to replace the Affordable Care Act suffered a major setback this week, as the U.S. Senate rejected three repeal bills. It may not be the last "near-death experience" for Obamacare, as Senate Majority Leader Mitch McConnell could bring one of the bills up again. But the Democratic caucus is unmovable on the issue, and it's not clear what could bring GOP Senators John McCain, Lisa Murkowski, or Susan Collins on board.
Iowa Senators Chuck Grassley and Joni Ernst voted for all three Republican bills, of course, as everyone following this debate had expected. Grassley told reporters earlier this week that he would support any legislation that could get 51 votes in the Senate, leading to conference negotiations with House Republicans. Though Ernst never expressed it in such terms, she too demonstrated that she was willing to vote for anything her leader brought to the floor, regardless of its costs and impact on Iowans.
Let's take a quick look at what Iowa's senators promised to stand for on health care policy, compared to what they voted for when the chips were down.
You can read several statements or form letters from Grassley and Ernst about health care reform here, here, here, and here. A common refrain for Ernst: "action is needed to ensure folks have access to affordable and patient-centered health care coverage." Grassley has repeatedly told constituents, "any health care reform plan has to address the rising cost of healthcare. [...] The American people deserve a long-term solution that gives them more choice for less cost."
Every bill they voted for this week would have increased health insurance premiums and reduced options, especially but not only for Americans who buy individual health insurance policies.
The Better Care Reconciliation Act was the first to come up for a vote this week. Sarah Kliff summarized its key points last month.
The Congressional Budget Office estimated that the bill would price millions of older people or people with pre-existing conditions out of the individual insurance market. Medicaid cuts would not only roll back the Medicaid expansion, but also affect those on "traditional" Medicaid, with devastating consequences for nursing homes and hospitals.
Grassley has repeatedly said one of his core principles on health care policy is "no one should be disqualified from getting insurance for having a pre-existing condition." Ernst has insisted that allowing more "flexibility" in health insurance policies would still protect people with pre-existing conditions.
Although the BCRA would not have formally excluded people with pre-existing conditions from buying insurance, every major health advocacy organization and the two largest health insurance industry groups reached the same conclusion: the bill would undermine protections and increase costs for people with pre-existing conditions.
In the end, nine Republican senators joined the whole Democratic caucus to vote the BCRA down on July 25. Ernst and Grassley showed more loyalty to their party than to their supposed principles.
The next day, McConnell brought up the Obamacare Repeal Reconciliation Act, often known as "repeal and delay." Timothy Jost described its key points and how the Congressional Budget Office evaluated its likely impacts.
The CBO projects that enactment of the ORRA would increase the number of uninsured by 17 million by 2018. By 2020 the number of uninsured would increase by 27 million and by 2026 to 32 million. By 2026, 59 million people would be uninsured, compared to 28 million under current law.
Much of the short-term increase would be due to individuals dropping or failing to renew individual, employer, he didn't knowor Medicaid coverage because of the end of the individual mandate penalty or to employers dropping coverage because of the end of the employer mandate penalty. But the CBO also notes that dramatic increases in premiums would drive insureds to drop coverage and discourage enrollment. Few low-income people would purchase coverage once the subsidies disappeared.
The CBO predicts that the end of the mandates and of the subsidies while the ACA’s insurance reforms remained in place would drive dramatic increases in premiums. Premiums for benchmark silver plans would increase 25 percent compared to current law by 2018, 50 percent by 2020, and double by 2026. Those who were able to find coverage with affordable premiums would face very high cost sharing.
The downward pressure on enrollment and upward pressure on premiums would drive insurers out of the individual market. The CBO projects that one tenth of the nation’s population would live in areas with no individual market coverage by 2018, half by 2020, three-quarters in area without any individual market insurers by 2026. Note that these would not just be “bare counties” without exchange coverage, a handful of which exist right now, but areas with no individual market coverage at all. Fewer than 2 million individuals would remain in the individual market by 2026.
In other words, more Americans would end up priced out of the market or living in areas with no individual health insurance options. Many people would lose employer-provided health insurance as well. The repeal-and-delay billfold also reverse Medicaid expansion.
Seven Republicans had the good sense to vote against this policy. Of course, Ernst and Grassley stuck with the rest of their caucus. In his July 25 conference call with Iowa reporters, Grassley admitted he didn't know what a final health care bill might look like. He was ready to vote for anything.
“I’ll give you a very 50,000-foot answer by saying what was said in caucus yesterday: Get something through the Senate,” Grassley answered when asked how he saw the ongoing and highly uncertain health care debate playing out in coming days.
“And ‘something’ was not very well defined,” Grassley added.
The GOP’s primary objective in the current debate, he said, is to pass a bill that can then be brought into conference — that is, negotiations with the U.S. House to find a compromise that both chambers could approve.
“Get something through the Senate that we can go to conference with the House and then during August get something worked out that can be brought back to the House and Senate that would be quote-unquote repeal and replace,” Grassley said.
Why would a House and Senate conference be able to come up with a better bill than what Republicans have been working on for seven months?
After the failure of repeal-and-replace and repeal-and-delay, Republican leaders spent part of July 27 writing a new "skinny repeal" bill called the Health Care Freedom Act, released in the evening just hours before a planned floor vote. From Kliff's explainer for Vox:
This HCFA would repeal the Affordable Care Act’s mandate that all Americans carry coverage. It would nix the requirement that large employers provide coverage to all workers, too. The bill includes a three-year repeal of the medical device tax and a one-year defunding of Planned Parenthood.
The Congressional Budget Office released an analysis late Thursday estimating that the HCFA would cause 16 million fewer Americans to have health coverage. The CBO has previously estimated that repealing the mandate to purchase coverage would raise premiums about 20 percent.
The CBO projected that already in 2018, 6 million people would lose employer-provided health insurance, on top of the 6 million losing individual health insurance.
The experience of Washington state during the 1990s indicates that repealing a mandate to purchase health insurance while retaining a requirement to cover people with pre-existing conditions would prompt insurers to flee individual markets.
Even Republicans admitted they didn't want this bill to become law--it was only a vehicle to get to a conference. Senator Lindsey Graham described skinny repeal as "half-assed" and a "disaster," "a fraud...terrible policy and horrible politics." No one can remember a time when senators were ready to vote for a bill on condition that the House not bring it up for a vote in the lower chamber. And Speaker Paul Ryan wasn't giving any guarantees; rather, House members were told to prepare for a possible floor vote on Saturday.
After tense negotiations on the Senate floor, with Vice President Mike Pence himself leaning on some resistant Republicans, McConnell finally resigned himself to failure. Skinny repeal came up one vote short.
But Grassley and Ernst were in the yes column again, even though the bill would have broken all of their promises to provide Iowans with more health care options at a lower cost.
A handful of principled Republicans stood up against policies that would harm their constituents this week. Too bad Iowa's senators weren't among them.
In statements released today, Grassley and Ernst repeated their talking points about Obamacare failing, not acknowledging that the bills they supported would have made insurance less accessible and less affordable, with higher premiums and deductibles. From Ernst:
“As I’ve said throughout this debate, ObamaCare is not sustainable in Iowa and we have to act. Iowans in the individual market have seen their choices vanish and have seen massive rate increases. Throughout my 99 county tour, I hear countless stories from Iowans facing these premium increases, as well as increases in other out of pocket costs like deductibles and copays that they simply cannot afford. We don’t have the option to sit back and do nothing; Iowans are demanding relief from ObamaCare.
“I am disappointed that the Senate was unable to advance important changes to this flawed law. We must now continue to find ways to work on behalf of Iowans and the American people who have been negatively impacted by Obamacare to find affordable, patient-centered solutions that work for them.”
The result is disappointing. The health care situation is the same as before. Obamacare has not delivered on its promises and is failing. Those who have access to insurance can't afford to use it because of sky-high deductibles, premiums and co-payments. Because of Obamacare's failures, 72,000 Iowans don't know if they'll be able to afford health insurance next year. Only one insurer will stay in the exchanges and plans premium increases of 43 percent on average, on top of big increases this year. The state of Iowa has a proposal pending with the federal government to try to save coverage for those individuals. Longer term, I'll continue to work for access to affordable health care by promoting the free market, supporting efforts to decrease the costs of prescription drugs, and making sure Medicare and Medicaid continue to be available to those who need them. The American people deserve better than Obamacare's failures.
UPDATE: The latest Des Moines Register story by Tony Leys includes some reaction from others in the health care industry.
Medica, the only carrier planning to sell individual health insurance policies in Iowa next year, said Thursday that if members of Congress passed the bill, they could worsen an already shaky market.
“If they repeal the individual mandate and do nothing else, they will be taking the one action universally understood to be bad. Premiums go up and the market becomes more unstable,” a Medica vice president wrote. [...]
Scott McIntyre, spokesman for the Iowa Hospital Association, hailed the defeat of the latest Senate health care bill.
“For vulnerable Iowans and their health care providers, this was a near miss that could have been catastrophic, so we are we are relieved at the outcome,” he wrote in an email to the Register. “Going forward, we see an opportunity for Congress to reset and refocus the health care discussion in an open, deliberative and bipartisan manner. While we remain committed to keeping Iowans covered, particularly those who depend on Medicaid, we welcome participating in further discussion with the goal of improving coverage and access to quality health care. We believe this is what Iowans both expect and deserve.”
The headline on the Register story ("Grassley and Ernst, who voted for ill-fated Obamacare repeal bills, aren't surrendering") and the tag line that shows up in the url ("Grassley and Ernst aren't abandoning the fight to rein in Obamacare") shows how "framing" can affect the way readers receive a story that is otherwise written in an "objective" way. Both of those titles depict Iowa's senators in a heroic role. These determined warriors trying to "rein in Obamacare" don't seem so impressive when you realize they keep voting for bills that would make health care less affordable or accessible.
Can they still try to pass something through reconciliation?
Or do they now need 60 votes for any healthcare legislation to pass the Senate? If the reconciliation route is closed to them now, perhaps some of the alleged GOP moderates will finally decide to work with Democrats to fix what needs fixing in Obamacare instead of grandstanding.