Senate Republicans this week released a revised version of their legislation to “repeal and replace” the Affordable Care Act, but Senate Majority Leader Mitch McConnell is struggling to find enough support even in his own party to bring the measure to the Senate floor for debate.
In the latest episode of the Kaiser Health News’ podcast What the Health?, KHN Senior Washington Correspondent Julie Rovner, along with Margot Sanger-Katz of the New York Times, Sarah Kliff of Vox.com and Joanne Kenen of Politico examine the difficulties in capping Medicaid funding. Does allowing consumers to purchase less comprehensive plans make it impossible for sick people to get affordable, comprehensive coverage?
Highlights of the podcast are below. The transcript has been edited for length and clarity.
Julie Rovner: So the Senate has gone home for the weekend but they left us Senate health bill 2.0 to chew over. And I thought we’d try to break down both the politics and the policy. Sarah, can you explain what Senate Majority Leader [Mitch] McConnell was trying to do with the tweaks that he made to this bill.
Sarah Kliff: Yeah, it was kind of like a split-the-baby-in-half sort of moment. But that’s obviously a very difficult thing to do and you can end up with a lot of upset people on both sides. I would argue [and] I’m curious if others agree that this is more of a shift to the right. That it is essentially a deregulation of the insurance market which is something that Sen. [Ted] Cruz from Texas and Sen. [Mike] Lee from Utah had really pushed for. And really allowing the return of plans that can deny coverage to sick people that cannot cover these essential health care benefits. And then there are a few of these, you know, sweeteners for moderates — more opioid funding, more funding for high-risk patients.
Joanne Kenen: I think it was a shift to the right. I think it was a shift to the right for a couple of strategic reasons. If [McConnell] had shifted to the moderates there’s no way the conservatives would have come on board. If he shifts to the conservatives and said, “look, I’m really trying to do it your way” and maybe there’s some kind of compromise in doing deals with the moderates. But it’s also a signal to the right in the House saying, “OK … I have very little room to move here. I can only lose three people. If I go to the left, I know I lose you guys. So I’m going to go to the right and I’m going to try to keep you guys. I’m going to do my best.” Because if he loses the right, he has no choice of getting the balance again.
Rovner: I want to turn back to the other side of the bill for a few minutes [to this] amendment that was being pushed by Ted Cruz, the conservative. And the conservatives in the House had this same problem, which is they said the biggest problem with the Affordable Care Act is that premiums are too high — they seem to be sort of leaving aside the idea that deductibles and other out-of-pocket spending is too high. They’re very concentrated on the premiums and they say that the way to get the premiums down [is] to make the plans less generous. If you don’t want all the benefits you can pay less and you’ll be better off and that led to whatever it was that they did in Senate bill 2.0. Who wants to jump in with a short explanation of the changes that they ended up making?
Margot Sanger-Katz: Basically what this part of the legislation would do is it would say: If you’re an insurance company, you have to offer a series of plans that are like the plans you offer under Obamacare. They adhere to all the Obamacare rules. You have to offer a gold, a silver and a benchmark plan. But then if you offer those plans you get access to some federal subsidies that help stabilize that part of the market — which come directly from the federal government to you, as an insurance company. They don’t go through states — and then you also would be allowed to offer different plans in the same parts of the state. And those plans I have been calling “no-rules plans.” So it’s not entirely true that there are no rules, but the legislation specifically waives almost all of the regulations that we think of as defining what health insurance is. … There are no minimum-benefit standards. There are no limitations on how much you can ask people to pay out-of-pocket for their own care. They are not required to offer insurance to everyone who buys it.
So if someone comes and wants to buy insurance they can say “no.” They are not required to make the insurance renewable. So if you have it for one year and you get sick and then you want to renew that policy at the end of the year they can say, “No thank you, I don’t want you to have this insurance anymore.” They are not required to charge the same price to people of different health status. They can say “I’ll cover you but I won’t cover your particular illness.” They can say “I’ll cover you but with a waiting period.” This is essentially anything-goes-kind-of market and it would operate alongside this market that has all of the Affordable Care Act rules. And I think when Ted Cruz proposed this idea his thinking was it sort of has something for everyone.