(Bloomberg View) – In defending the unpopular and flawed House bill to replace the Affordable Care Act, a common Republican refrain is that it fully protects health-insurance coverage for people with pre-existing medical conditions.
"Under this bill, no matter what, you cannot be denied coverage if you have a pre-existing condition," insisted House Speaker Paul Ryan, a talking point echoed by President Donald Trump.
Nervous Republican congressional candidates will clamor to make the same argument. Take Karen Handel, the Republican locked in a tight Georgia special-election contest to replace Tom Price, who left Congress to become Trump's secretary of health and human services. "No one can be denied insurance because of pre-existing conditions," she says on the stump.
Such duplicity! People with pre-existing conditions cannot be denied coverage outright but, as the Congressional Budget Office just reported, many of them would face huge increases in the cost. Anticipating such bad news, Ryan rushed the bill through the House last month before the CBO analysis was released on May 24.
The Affordable Care Act, unpopular since it was enacted by President Barack Obama and a Democratic Congress in 2010, is gaining backing as the Republican alternative takes shape. But one constant has been public support for some ACA provisions, including overwhelming approval of the rule that premiums can't vary based on medical history or health status.
This guarantee costs money, which is why Republicans are trying to dilute it.
The House bill permits states to get waivers from coverage rules under certain circumstances. The CBO estimates that states that are home to half the U.S. population would do that, and that the effect would be to raise the cost of coverage for those with pre-existing conditions, in some cases considerably.
The bill also allows insurers charge higher premiums to people who let coverage lapse for 63 days. The Kaiser Family Foundation estimates that 6.3 million people with pre-existing conditions have such gaps in a year, sometimes after they lose a job.
The architects of the House bill, realizing the political danger, set aside $100 billion over 10 years for states to subsidize insurance costs for people whose medical history drives up their premiums. But these "high-risk pools," health experts say, have a mixed record. Kaiser and others estimate that they would cover less than one-third of the potential additional costs for those with pre-existing conditions.
To pick up votes for the House bill from nervous colleagues, Michigan Republican Fred Upton added $8 billion over five years to help people with pre-existing conditions. This was a political ploy; it's a drop in the bucket compared to the need.
Further, the bill's separate slashing of Medicaid spending would clobber some of this group. Among low-income adults benefiting from the ACA's expanded Medicaid coverage, almost 30 percent have mental illness or substance-abuse disorders like opioid addiction.
In 2009, Senate Democrats passed the Affordable Care Act with no Republican votes. Two committees, however, had spent six months on the measure. The Senate Finance Committee held dozens of hearings and there were scores of hours of negotiations with Republicans that ultimately were unsuccessful.
By contrast, Senate Republicans now have 13 members meeting in secret to hammer out the Senate version of an ACA replacement. They are toying with a full rewrite of the House bill, but party consensus is elusive. More likely are minor modifications to the House plan, such as stretching out effective dates beyond election years and adding a little money. They then would take this directly to the Senate floor this summer, without hearings or public testimony, and try to pass it with Republican votes alone.
Under rules of this procedure, the bill has to be analyzed by the CBO. Since the differences from the House bill would be minor, the CBO findings won't be much better for Republicans.
But there's a catch. Any changes adopted by the full Senate don't have to be analyzed by the CBO. Thus, sources close to these deliberations say, the plan would include cosmetic changes that would provide talking points to deflect criticism -- much as Upton's tweaks did for his House colleagues (there's even a cynical new legislative verb now in use, "to Upton"). The leadership then would try to persuade or pressure the handful of Republican moderates and health care experts to go along in order to achieve a political win.
Not so long ago, one of the Senate's foremost health-care experts had a warning for Democrats as they prepared to pass the ACA:
"Thumbing their nose at the American people by ramming through a partisan bill would be the same thing as going to war without asking Congress' permission," he said. "You might technically be able to do it, but you'd pay a terrible price in the next election."
That was Tennessee Republican Lamar Alexander in 2009. Today he's one of those 13 Republicans hunkered down in the Capitol.
This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.
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