tag:theconversation.com,2011:/global/topics/repeal-and-replace-35718/articlesRepeal and Replace – The Conversation2017-12-05T04:07:59Ztag:theconversation.com,2011:article/886242017-12-05T04:07:59Z2017-12-05T04:07:59ZHow the tax bill opens wide a big back door to overhaul health care<figure><img src="https://images.theconversation.com/files/197683/original/file-20171204-23009-c5oo4h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Senate Majority Leader Mitch McConnell in a Nov. 30, 2017 photo as he talked to small business owners about the tax bill. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Taxes/81b0a4ec46e24eee91b2adf1385e2ff1/58/0">AP Photo/J. Scott Applewhite</a></span></figcaption></figure><p>The U.S. Senate on Dec. 2 <a href="https://www.nytimes.com/2017/12/01/us/politics/senate-tax-bill-debate-vote.html?_r=0">passed its version</a> of <a href="http://www.factcheck.org/2017/11/trumps-claims-dont-add/">one of the most sweeping tax reform bills</a> on a party-line vote of 51-49. After reconciliation with a House version, the bill is expected to be passed into law by the end of the year.</p>
<p>The process and content of the legislation is largely reminiscent of the <a href="https://theconversation.com/how-the-latest-effort-to-repeal-obamacare-would-affect-millions-84317">previous efforts by Republicans to repeal the Affordable Care Act</a>: <a href="https://www.nytimes.com/2017/11/16/us/politics/house-tax-overhaul-bill.html">limited hearings</a>, limited analysis, limited participation and limited transparency. By providing various concessions, Senate Republican leadership was able to convince its <a href="http://thehill.com/homenews/senate/344270-mccain-votes-to-kill-gops-skinny-backup-obamacare-repeal-plan">three holdouts</a> <a href="https://theconversation.com/how-the-latest-effort-to-repeal-obamacare-would-affect-millions-84317">from the bill that would have gutted the Affordable Care Act</a> from earlier this year: Republican Senators John McCain of Arizona, Lisa Murkowski of Alaska and Susan Collins of Maine. “Tax reform” essentially morphed into the <a href="https://www.vox.com/health-care/2017/12/1/16725326/obamacare-mandate-tax-bill-voxcare">functional equivalent of this summer’s “skinny repeal</a>” version of “repeal and replace.”</p>
<p>As a professor of health policy, I see this “tax reform” as “health care reform” by another name. We may simply have seen the opening of the door for much more far-reaching efforts to transform American social programs over the coming years. </p>
<h2>Effects beyond Obamacare</h2>
<p>The most obvious effect of the Senate tax reform bill is the repeal of the <a href="https://www.cbo.gov/budget-options/2016/52232">individual mandate established by the Affordable Care Act</a>. The provision required most Americans <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/full">to obtain insurance coverage or pay a fine</a> and has long been the most disliked component of the ACA.</p>
<p>While perhaps <a href="https://www.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-august-2017-the-politics-of-aca-repeal-and-replace-efforts/">the least liked part of the ACA</a>, the mandate serves as a crucial component to <a href="https://theconversation.com/how-the-latest-effort-to-repeal-obamacare-would-affect-millions-84317">stabilize insurance markets</a> around the country. It was crucial because it limited the potential for something called <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">adverse selection</a>, whereby only the sickest individuals, usually those with high medical costs, sign up for insurance. Without a requirement to carry insurance, and with insurers required to offer insurance to all comers, healthy individuals are likely to only sign up when they get sick if there is no mandate.</p>
<p>Without the requirement to purchase insurance, the Congressional Budget Office predicts that <a href="https://www.cbo.gov/publication/53300">13 million fewer Americans</a> will have health insurance. Potentially, and equally significant, insurance markets will likely be further destabilized. Insurance companies may decide to further <a href="https://www.cbo.gov/publication/53300">reduce the number of policies they offer in the insurance marketplaces, or even stop offering policies</a>. As a result, potentially millions of Americans could be left without options to purchase insurance.</p>
<p>Without further actions, the bill would also trigger an automatic reduction in Medicare spending <a href="https://www.cbo.gov/publication/53319">of US$500 billion over 10 years</a>. Republicans would have to pass separate legislation, with Democratic support, to avoid this scenario.</p>
<p>Moreover, the Senate’s tax reform also does more subtle things, including reducing the <a href="https://khn.org/news/patients-with-rare-diseases-and-congress-square-off-over-orphan-drug-tax-credits/">incentives for pharmaceutical companies</a> to develop drugs for rare disease. It also extends taxes to graduate student tuition waivers and eliminates the <a href="http://www.thecrimson.com/article/2017/12/1/students-criticize-tax-plan/">student loan interest deduction</a>, both crucial for future physicians and researchers.</p>
<h2>In the long run: Starving the beast?</h2>
<p>However, while the effects of the legislation, if enacted, will be felt immediately, the most crucial implications may lie in the future. The tax bill is projected to add <a href="https://www.nytimes.com/interactive/2017/11/28/us/politics/tax-bill-deficits.html">$1 trillion</a> to the federal deficit. As a result, Republicans will likely move to cut funding to all of America’s social programs, from food stamps to Medicare and Social Security, with privatization being the final goal.</p>
<p>This is consistent with long-term goals of the Republican Party. Going back to the <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">New Deal and the Great Society</a>, large parts of the GOP have been opposed to the creation and extension of social programs like Social Security and Medicare. </p>
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<img alt="" src="https://images.theconversation.com/files/197682/original/file-20171204-23018-43d4ab.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/197682/original/file-20171204-23018-43d4ab.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/197682/original/file-20171204-23018-43d4ab.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/197682/original/file-20171204-23018-43d4ab.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/197682/original/file-20171204-23018-43d4ab.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/197682/original/file-20171204-23018-43d4ab.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/197682/original/file-20171204-23018-43d4ab.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">President Reagan celebrates with his staff in the Oval Office the passage of Federal Tax Legislation, the first of the two ‘Reagan cuts’ (July 29, 1981).</span>
<span class="attribution"><a class="source" href="https://reaganlibrary.gov/photo-galleries/white-house-staff-and-meetings">Ronald Reagan Library</a></span>
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<p>Yet, once enacted, the programs largely proved incredibly popular. Historically, they became virtually impossible to undo because of large popular and interest group support.</p>
<p>Because those programs proved impervious to frontal assault, Republicans have opted for a backdoor strategy. </p>
<p>First, they have sought to reduce the ability of government to raise revenues. Over time, accumulating deficits and debt would inevitably trigger the need for adjustments to either taxes or social programs. </p>
<p>They then could implement the second step. Figuring that Americans would be loathe to give up their tax cuts, Republicans would then be able to cut and potentially privatize even the most popular social programs. </p>
<p>In short, they would force reductions in social spending by reducing the ability of government to fund these programs, a strategy that has been called <a href="https://object.cato.org/sites/cato.org/files/serials/files/policy-report/2004/3/cpr-26n2-2.pdf">“starve the beast.”</a></p>
<p>The first major success using this strategy was the <a href="https://www.finance.senate.gov/imo/media/doc/Hrg95-93.pdf">indexing of tax brackets in the 1970s</a>. Previously, government tax receipts had grown implicitly as inflation pushed taxpayers into higher tax brackets. To a large degree, Democrats had not been required to raise taxes for social spending. </p>
<p>When indexing and cuts did not prove enough to trigger major reductions in social programs, Republicans, and many conservative Democrats, pushed through <a href="https://taxfoundation.org/comparing-kennedy-reagan-and-bush-tax-cuts/">major cuts </a> under the Reagan and Bush administrations.</p>
<p>Yet, Republicans had not expected the public’s reaction: Taxpayers wanted their cake and to eat it, too; taxpayers loved their reduced taxes, but the demand for social spending went unabated. The results are obvious today: Federal deficits cumulative driving the national debt <a href="http://www.usdebtclock.org/">above $20 trillion, or 106 percent of GDP</a>.</p>
<p>Fast-forward to 2017. Republican efforts to undo the ACA have gone significantly beyond the Obama administration’s signature accomplishment and include <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">transformational changes to the Medicaid program</a>. Talk about <a href="https://www.washingtonpost.com/news/wonk/wp/2017/12/01/gop-eyes-post-tax-cut-changes-to-welfare-medicare-and-social-security/">privatizing Social Security and Medicare</a> has also been common. </p>
<p>Republicans have not able to accomplish any of it outright. But further increasing the federal deficit may just be enough to make significant changes to our nation’s social programs. Republican leaders are doubling on down on their strategy. Starving the beast may finally work.</p>
<h2>Health care will change</h2>
<p>The changes to the health care of many Americans potentially ushered in by tax reform are significant and damaging. Many Americans will lose access to health insurance, costs are <a href="https://www.aarp.org/politics-society/advocacy/info-2017/senate-tax-premiums-fd.html">projected to increase</a> and fewer individuals will be able to <a href="https://theconversation.com/tax-bills-attack-on-higher-education-undermines-americas-economic-vitality-88428">afford getting an education</a>. People will be hurt.</p>
<p>The long-term implications may be even more significant and culminate in transformational changes to American social program not seen since the 1960s. If successful, Republicans may prove successful in their long-running quest to undo the health protections the country has had since the New Deal and the Great Society.</p><img src="https://counter.theconversation.com/content/88624/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Senate tax bill cuts taxes for many of the nation’s richest and cuts programs for social safety nets. Here’s how the Affordable Care Act, Medicare and Medicaid are all affected.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/815952017-07-26T01:00:25Z2017-07-26T01:00:25ZSenate GOP opens health care debate. Now what?<p><em>On July 25, Senate Majority Leader Mitch McConnell narrowly managed to keep a Republican effort to reform health care alive. We asked our experts to consider the importance of this procedural vote and what happens next.</em></p>
<p><strong>Jeffrey Lazarus, Georgia State University</strong></p>
<h2>Which bill will it be?</h2>
<p>Senate Republicans have voted to start debate on a health care bill. The “motion to proceed” – which marks the start of debate on bills in the Senate – reached a majority on the strength of “yes” votes from senators who previously voted “no,” including Rand Paul, Dean Heller and Shelley Moore Capito; <a href="http://www.cnn.com/2017/07/25/politics/john-mccain-votes/index.html">John McCain’s quick return</a> to Washington after a brain cancer diagnosis; and <a href="https://www.senate.gov/pagelayout/reference/four_column_table/Tie_Votes.htm">a rare tie-breaking vote</a> from Vice President Pence. </p>
<p>While this is a major step in the legislative process in the Senate, it’s important to remember that today’s vote is procedural, not substantive. No bill has passed. All that has happened is that the Senate will begin formal debate. </p>
<p><a href="https://theconversation.com/mitch-mcconnell-the-presidents-man-in-the-senate-81377">Majority Leader Mitch McConnell</a> depended on a couple of factors to help get the motion passed. First, members are more likely to support their parties on <a href="http://www.ucpress.edu/book.php?isbn=9780520072206">procedural votes</a> than votes directly attached to whether a bill should pass. Second, this particular procedural vote has almost no substance; nobody knows what the Senate bill will look like, so it’s unclear what exactly the Senate just agreed to debate. Since the health care bill is massively unpopular, this lack of substance probably helped get marginal senators on board. </p>
<p>So what bills could McConnell now bring up?</p>
<p>One is <a href="http://abcnews.go.com/Health/wireStory/republican-sens-mike-lee-jerry-moran-announce-opposition-48691742">the bill</a> the Senate was working on before it all but died when four GOP senators – Mike Lee, Jerry Moran, Susan Collins and Rand Paul – announced they would vote against it. </p>
<p>A second is a <a href="https://www.washingtonpost.com/news/wonk/wp/2017/07/19/heres-what-health-care-looks-like-if-republicans-new-obamacare-repeal-plan-succeeds/?utm_term=.518abd09b6dd">“repeal and delay” option</a>, which would repeal Obamacare in full, but on a two-year delay. This would give Congress more time to come to an agreement on what a replacement should look like. </p>
<p>Unless a number of senators reverse their public opposition, neither of these two bills is likely to pass. </p>
<p>The third option is a <a href="http://thehill.com/policy/healthcare/343611-senate-gop-floats-scaled-down-healthcare-bill">“skinny” bill</a> with a small number of relatively popular provisions. One possibility would repeal Obamacare’s individual and employer mandates, and the medical device tax, but leave the rest of Obamacare intact. This has a better chance of passing. It’s also primarily intended to simply get the Senate to conference committee, where senators and House members could continue negotiations on what the final bill should look like. </p>
<p><em>Jeff Lazarus is the author of “Gendered Vulnerability: How Women Work Harder to Win Reelection,” coming in 2018 from University of Michigan Press.</em></p>
<hr>
<p><strong>David McLennan, Meredith College</strong></p>
<h2>Who will lead the Senate health care debate?</h2>
<p>Senate Republicans voted by the narrowest of margins – 51-50 – to begin debate to repeal and replace the Affordable Care Act. Several days ago even this procedural victory appeared unlikely.</p>
<p>McConnell scheduled today’s vote even though <a href="http://www.cnbc.com/2017/06/28/senate-gop-health-care-bill-has-dismal-approval-rating-poll.html">several polls</a> show the bill’s low public approval. With the help of President Donald Trump, McConnell pressured just enough senators to vote in favor of the motion – including Dean Heller and Rand Paul – who previously said they had concerns with Republican reform ideas.</p>
<p>Although McConnell and Trump successfully used their positions to pressure critics such as <a href="http://talkingpointsmemo.com/dc/ron-johnson-wisconsin-obamacare-repeal-mcconnell-medicaid">Ron Johnson of Wisconsin</a>, one of the most vocal critics of the process used in the Senate, it is unlikely the tactics used to squeeze 50 Republican senators to vote to allow debate will translate into a Republican bill that repeals and replaces Obamacare.</p>
<p>The likely leaders in the next phase of the Republican attempts to reform health care will come from different parts of the caucus. Their arguments in the upcoming debates will be forceful and not amenable to the pressures of McConnell or Trump.</p>
<p>Susan Collins of Maine, one of two Republicans who voted against the motion to debate, leads the group of moderate Republicans and has been clearest about the need for <a href="http://www.cnn.com/2017/07/10/politics/republican-susan-collins-health-care-bill-complete-overhaul/index.html">starting over on reform</a>. </p>
<p>McCain made an emotional return to the Senate floor to cast his vote to proceed with debate, even while <a href="http://thehill.com/homenews/senate/343703-mccain-urges-senators-to-work-together-on-healthcare-in-fiery-speech">criticizing the Republicans’ bill</a> and the process used by McConnell. McCain represents the mainstream Republicans who want to follow a more traditional legislative process.</p>
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<figcaption><span class="caption">McCain: “We’re getting nothing done.”</span></figcaption>
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<p>Rand Paul of Kentucky, speaking for the libertarian wing, argues that nothing short of <a href="http://www.washingtonexaminer.com/rand-paul-crony-capitalism-isnt-a-right-so-why-does-senate-healthcare-bill-give-insurance-companies-the-right-to-a-bailout/article/2628572">a complete repeal of the ACA</a> with no reform that offers government subsidies is the best solution.</p>
<p>The Republican caucus remains divided about the way forward on health care reform. However, with a weakened majority leader and an unpopular president, it will be interesting to see who emerges as a leader in the next few weeks.</p>
<p><em>David McLennan is the author of <a href="http://www.meredith.edu/images/uploads/women-nc-politics.pdf">“Women in North Carolina Politics</a>.”</em></p>
<hr>
<p><strong>Rachel Paine Caufield, Drake University</strong></p>
<h2>What about the president’s agenda?</h2>
<p>It was a dramatic day on Capitol Hill. Unable to craft a “repeal and replace” bill with support from the Republican caucus, the Senate leadership has opted for a truly exceptional open amendment process, meaning senators will squabble over details in public.</p>
<p>So what does this vote portend for Trump’s policy agenda on health care and other issues?</p>
<p>That the House and Senate started with health care reform says something about their policy goals. They could have highlighted an effort to work with Democrats and started with <a href="http://fortune.com/2017/02/28/trump-congress-address-infrastructure-investment/">Trump’s proposal</a> to spend US$1 trillion to update and improve America’s infrastructure. They could have brought the Republican caucus together and begun work on tax reform, <a href="https://www.whitehouse.gov/blog/2017/04/26/president-trump-proposed-massive-tax-cut-heres-what-you-need-know">a priority for Trump</a>. There may be good reasons to start with health care, including a procedural desire to use the <a href="https://www.senate.gov/reference/glossary_term/reconciliation_process.htm">reconciliation</a> process and the need to <a href="http://www.foxbusiness.com/politics/2017/04/11/health-care-reform-first-will-pave-way-for-tax-reform-trump-exclusive.html">rely on savings from health care reform to justify widespread tax cuts</a>. But the issue has demonstrated the deep ideological, geographic and policy <a href="http://www.businessinsider.com/republicans-lost-a-few-seats-divisions-run-deep-2016-11">differences</a> within the party. Putting those divisions front and center at this early stage engenders an image of chaos and could exacerbate later efforts to find common ground on other issues.</p>
<p>Like all presidents, Trump spent his campaign laying out a series of <a href="http://www.politifact.com/truth-o-meter/promises/trumpometer/">policy commitments</a>. Unlike most presidents who have had experience negotiating the fine points of policymaking, Trump is relying on congressional leaders to fill in the blanks and make his policy commitments real. <a href="http://home.uchicago.edu/%7Ewhowell/papers/Divided.pdf">Unified government generally yields more “landmark” legislation</a>, but the current health care debate suggests that Trump will have a hard time leading his party forward on immigration reform, infrastructure spending, financial deregulation and tax cuts.</p>
<p>Trump seems ambivalent about the details of this policy debate. While campaign rhetoric to “repeal and replace” may be popular among Republican voters, actual reform is fraught with risks to Republican lawmakers, including the <a href="https://www.washingtonpost.com/news/politics/wp/2017/07/16/by-a-2-to-1-margin-americans-prefer-obamacare-to-republican-replacements/?utm_term=.40d069b87a5b">unpopularity</a> of Republican alternatives. Republican legislators see a mandate to move forward decisively on this issue, but the president has not proven to be a consistent leader in this effort. To the extent that the president’s agenda will be achieved, it will be because Republican leaders in Congress share his goals and are willing to hash out the details among their members.</p>
<p><em>Rachel Paine Caufield is the author of <a href="https://www.arcadiapublishing.com/Products/9781467115834">“The Iowa Caucus</a>.”</em></p><img src="https://counter.theconversation.com/content/81595/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Mitch McConnell gets a win, and the Republican efforts to repeal Obamacare will be debated in the Senate.Jeffrey Lazarus, Associate Professor of Political Science, Georgia State UniversityDavid McLennan, Professor of Political Science, Meredith CollegeRachel Paine Caufield, Associate Professor, Drake UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/803082017-07-19T06:40:40Z2017-07-19T06:40:40ZRepublicans fail on health care. Here’s why the rest of Trump’s agenda won’t be ‘so easy,’ either<figure><img src="https://images.theconversation.com/files/178724/original/file-20170718-24356-pnpncr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sen. Rand Paul speaks at a news conference on Capitol Hill.</span> <span class="attribution"><span class="source">AP Photo/Andrew Harnik</span></span></figcaption></figure><p>Passing legislation is always a difficult, messy task. America’s highly polarized political environment, with party activists demanding ideological purity on both sides of the aisle, makes that task even harder.</p>
<p>The announcement by Senators Mike Lee and Jerry Moran that they would oppose bringing the Better Care Reconciliation Act to the Senate floor has <a href="https://www.nytimes.com/2017/07/17/us/politics/health-care-overhaul-collapses-as-two-republican-senators-defect.html?_r=0">derailed Republican attempts</a> to replace the Affordable Care Act. </p>
<p>During his campaign, <a href="https://www.realclearpolitics.com/video/2016/10/25/trump_repealing_obamacare_is_going_to_be_so_easy.html">Donald Trump claimed</a> that passing health care reform would be “so easy.” So why were Republicans unable to pass a health care law despite controlling both the White House and Congress?</p>
<p>It turns out that the relationship between Congress and the president is more complicated than Trump thought. Most citizens and <a href="https://www.amazon.com/Ideology-Congress-Keith-T-Poole/dp/1412806089">political scientists</a> assumed that conservative Republicans <a href="http://press.uchicago.edu/ucp/books/book/chicago/P/bo3616471.html">would prefer any health care law</a> that Trump supported over the Obamacare status quo.</p>
<p>However, my <a href="http://www.tandfonline.com/doi/abs/10.1080/07343469.2015.1122671">research</a> shows that this assumption is too simplistic. As Trump now knows, ideological extremists may also vote against bills proposed by their party’s president. The recent struggle to pass a Republican health care law is a prominent example of this phenomenon.</p>
<h2>Trump’s two-sided task</h2>
<p>President Trump, House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell are waging a legislative battle on two fronts with no compromise in sight. Both moderate Republicans and extremely conservative Republicans oppose the current health care bill for <a href="https://www.nytimes.com/interactive/2017/07/13/us/senate-health-care-bill-changes.html">completely separate reasons</a>.</p>
<p>Moderate Republicans are concerned about how Medicaid cuts and changes to Obamacare regulations, like guaranteed essential health benefits and protections for people with preexisting conditions, will affect their constituents. On the other hand, extremely conservative Republicans want to both remove those Obamacare regulations and repeal all Obamacare taxes. This puts Republicans leaders in a bind. Anything they do to please moderates will tend to alienate the extreme conservatives, and vice versa.</p>
<p>The House passed the American Health Care Act thanks to support from extremely conservative members who switched their votes to <a href="https://www.nytimes.com/2017/04/26/us/politics/affordable-care-act-health-republicans.html">support the bill</a>. This may explain why Majority Leader McConnell’s strategy seemed more focused on winning conservative support than moderate support. The major change to the most recent version of the health care bill was the Cruz Amendment, which would allow insurance companies to offer low-cost plans that provide coverage that is much less than the <a href="http://thehill.com/policy/healthcare/341828-new-gop-healthcare-bill-includes-version-of-cruz-amendment">standards set by Obamacare</a>. Yet this bill did not provide <a href="http://www.nbcnews.com/politics/congress/major-health-care-changes-senate-gop-bill-n782691">funding for Planned Parenthood or protect Medicaid</a>, two provisions that a number of moderate Republicans like Susan Collins, Shelley Moore Capito, Rob Portman and Lisa Murkowski wanted to see included.</p>
<p>The president’s strategy seemed to focus on conservatives as well. The list of senators invited to the White House on July 17 to solidify support for the bill included a number of conservative senators and <a href="http://www.politico.com/story/2017/07/17/trump-obamacare-repeal-senators-outreach-240636">almost no moderates</a>. </p>
<h2>Moving down the agenda</h2>
<p>After the original bill’s failure, both Trump and McConnell wanted the Senate to vote on a bill to completely repeal the Affordable Care Act <a href="http://abcnews.go.com/Politics/mcconnell-calls-obamacare-repeal-vote-replacement-plan-fails/story?id=48690900">after a two-year delay</a>. This gambit was essentially Republican leadership playing chicken in two ways.</p>
<p>First, leadership dared rank-and-file Republicans to vote against a repeal bill because most Republicans campaigned on the premise that the ACA should be repealed. However, doing so could potentially create chaos in the health care market.</p>
<p>Second, if Congress failed to pass a replacement health care bill within the next two years, chaos would ensue. Congress often gives itself such incentives in order to <a href="https://www.polisci.washington.edu/research/publications/congress-and-politics-problem-solving">promote compromise</a>. The major problem with this tactic is that Republican leadership would still have to find a way to placate both moderates and extreme conservatives, and potentially Democrats as well. While legislative compromise used to be a regular occurrence, it is becoming rarer in recent times due to increased polarization. Legislative productivity is near an <a href="https://www.washingtonpost.com/news/the-fix/wp/2014/04/10/president-obama-said-the-113th-congress-is-the-least-productive-ever-is-he-right/?utm_term=.11d0739d6811">all-time low</a>.</p>
<p>The August 2011 budget deal is the last major example of Congress creating a potentially negative situation in order to incentivize cooperation. The bill created the “sequester,” which threatened to cut government spending across the board beginning in 2013 if Congress was unable to come to <a href="http://money.cnn.com/2011/08/01/news/economy/debt_ceiling_breakdown_of_deal/index.htm">an agreement by that date</a>. The idea was that neither Democrats nor Republicans wanted that to happen, so they would be forced to make a deal. While the sequester was intended to bridge differences between the two parties, a repeal and delay plan would be intended to bring Republican moderates and extreme conservatives to the bargaining table.</p>
<p>The trouble is that the sequester gambit failed miserably. While Congress made some small deals on both military and social spending, the 2011 sequestration agreement is still largely in effect. It <a href="https://www.theatlantic.com/politics/archive/2017/03/donald-trump-meet-sequestration/519798/">looms over budget policy today</a>. Democrats and Republicans still refuse to compromise on most budgetary issues. Republicans run the risk of the same thing occurring with health care policy if they decide to fully repeal the Affordable Care Act without a replacement in place.</p>
<p>In order to repeal and replace Obamacare, Republicans needed to strike a deal that pleased both moderates and conservatives. It seems unlikely that such a deal exists. </p>
<p>The big question moving forward is whether such a deal is possible on taxes, infrastructure, the border wall and other major parts of President Trump’s legislative agenda. In my opinion, tax reform is the item that is most likely to become law. But Republicans’ failure on health care could foreshadow an inability to bridge the moderate-conservative divide on other major issues as well.</p><img src="https://counter.theconversation.com/content/80308/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patrick T. Hickey does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It turns out a unified government isn’t enough to get bills passed.Patrick T. Hickey, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/810132017-07-14T02:41:37Z2017-07-14T02:41:37ZWhy health savings accounts are a bust for the poor but a boost for the privileged<figure><img src="https://images.theconversation.com/files/178181/original/file-20170713-9618-8l6p7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">North Carolina NAACP President Rev. William Barber, accompanied by Rep. Sheila Jackson Lee, Texas, left, as activists, many with the clergy, are taken into custody by U.S. Capitol Police on Capitol Hill in Washington, July 13, 2017, after protesting against the Republican health care bill.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/Search?query=health+care+bill&ss=10&st=kw&entitysearch=&toItem=15&orderBy=Newest&searchMediaType=excludecollections">AP Photo/J. Scott Applewhite</a></span></figcaption></figure><p>When Senate Majority Leader Mitch McConnell released his <a href="https://www.nytimes.com/2017/07/13/us/politics/senate-republican-health-care-bill.html">new version of the Republican health care bill</a> July 13, he relied on a favorite Republican device to solve the nation’s health care woes – Health Savings Accounts.</p>
<p><a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">Health Savings Accounts</a> (HSAs) were established by the same legislation that created the Medicare Part D prescription drug benefit in 2003. <a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">HSAs</a> allow individuals to make tax-deductible contributions, withdraw money tax-free to pay for qualified medical expenses and avoid taxes on the money invested in the account.</p>
<p><a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">Enrollment in HSAs</a> has skyrocketed to nearly 20 million people, but there’s a catch. Very few, if any, of those 20 million people are poor. The HSAs allow individuals to use tax-protected funds for medical purposes for years to come. Some have even called them the <a href="https://www.wageworks.com/blog/2016/july/07/health-savings-accounts-the-new-401k#sthash.eA4uob07.dpbs">“new 401(k)‘s</a>.”</p>
<p>While these savings accounts can be good for people of a certain income level, I have concerns that they will overlook the needs of the poor, who not only stand to gain very little from the tax advantages but who also are unlikely to have thousands of dollars to contribute to such plans.</p>
<h2>Tax savings and a dose of financial responsibility</h2>
<p>Currently, individuals are allowed to make <a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">annual contributions</a> of US$3,400, while families are allowed to contribute up to $6,750. Unlike so-called health Flexible Spending Accounts, or FSAs, left-over assets in the account carry over from year to year. In 2015, the average balance was just over $1,800.</p>
<p>Individuals are able to establish HSAs only when they obtain coverage through so-called High-Deductible Health Plans (HDHPs), which are currently defined as plans with a deductible of at least $1,300 for single people, or at least $2,600 for family coverage. The maximum out-of-pocket cost for individuals and families are $6,450 and $12,900, respectively.</p>
<p>This means that individuals with these plans are responsible for a significant amount of costs before their insurance benefits kick in. There are no data that show how many people of lower income could afford to fund these plans.</p>
<p>What we do know is that there are about <a href="https://www.ebri.org/publications/ib/index.cfm?fa=ibDisp&content_id=3397">20-22 million policyholders</a> with <a href="https://www.ebri.org/publications/ib/index.cfm?fa=ibDisp&content_id=3397">$28 billion in assets</a>. </p>
<p>In larger employers, <a href="https://www.mercer.com/content/dam/mercer/attachments/private/gl-2017-health-national-survey-infographic-series-mercer.pdf">53 percent of employers offer HSAs, and about a quarter of employees are covered</a>. About <a href="http://www.kff.org/health-reform/poll-finding/survey-of-non-group-health-insurance-enrollees-wave-3/">half of individuals</a> obtaining insurance in the individual market do so via a high-deductible plan. This number is expected to <a href="http://healthaffairs.org/blog/2015/10/07/trouble-ahead-for-high-deductible-health-plans/">continue to grow in the future</a>.</p>
<h2>Why are conservatives enamored of HSAs?</h2>
<p>When it comes to conservative ideology, HSA checks off a number of boxes. </p>
<p>For one, they are supposed to empower the individual to take charge of their own health care decisions. With <a href="https://www.jstor.org/stable/1813785?seq=1#page_scan_tab_contents">more “skin in the game,” individuals will be incentivized to make better, more prudent choices</a> when it comes to their health care. This should not only reduce premiums for individuals and families, but equally important, rein in the growth of U.S. healthcare expenditures.</p>
<p>Lower premiums, in turn, would then allow more Americans to obtain insurance coverage. They would also ease the tremendous burden on American companies seeking to provide health insurance to their employees.</p>
<p>HSAs also reduce the tax burden of Americans, albeit mostly for the wealthier part of society. Moreover, the funds in HSAs will provide investment capital to America’s economy and lead to further economic growth.</p>
<h2>Disadvantages of HSAs?</h2>
<p>A handful of studies have been able to provide some insights into potential benefits and problems of HSAs and HDHPs. Most of the studies confirm the general findings of the famous <a href="https://www.rand.org/content/dam/rand/pubs/reports/2006/R3055.pdf">RAND Health Insurance Experiment</a>: Higher deductibles lead to a reduction in the quantity of medical care consumed. The experiment also showed that, on average, this reduction was not detrimental to individuals’ health status.</p>
<p>However, there was one significant exception: Low-income individuals with chronic conditions saw a significant drop in health status.</p>
<p>More recent studies have shown that HDHPs and HSAs lead to spending about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2910568/">5-7 percent less</a> on medical care per enrollee. Most of these reductions come from <a href="http://www.ajmc.com/journals/issue/2013/2013-1-vol19-n12/medication-utilization-and-adherence-in-a-health-savings-accounteligible-plan/P-1">reducing the amount of care consumed</a> – <a href="http://www.nber.org/papers/w21632?utm_campaign=ntw&utm_medium=email&utm_source=ntw">not from shopping for cheaper providers</a>. There is also evidence that individuals <a href="http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_152.pdf">delay care</a>, <a href="http://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-lchs-dig-deep-hidden-costs-112414.pdf">do not comply with doctors’ treatment plans</a> and <a href="http://content.healthaffairs.org/content/31/12/2641.full.pdf+html">are unaware of free preventive services</a>.</p>
<p>None of these findings is surprising.</p>
<p>We know that <a href="http://www.bankrate.com/banking/savings/survey-how-americans-contend-with-unexpected-expenses">many Americans do not have enough savings to account for an emergency</a>, medical or otherwise. The wealthiest Americans disproportionately benefit from these insurance arrangements. Indeed, <a href="https://www.cbpp.org/blog/trump-house-gop-health-savings-account-proposals-would-mostly-help-wealthy-not-uninsured">families making in excess of $100,000 make up 70 percent of HSA contributions</a>. </p>
<p>CNN Money called HSAs “<a href="http://money.cnn.com/2017/05/05/pf/hsa-health-savings-account/index.html">the best tax-free investment account you’ll be able to find</a>.”</p>
<p>We know that American health care consumers are notoriously <a href="http://www.kff.org/health-reform/poll-finding/assessing-americans-familiarity-with-health-insurance-terms-and-concepts/">bad at understanding the U.S. insurance and health care system</a>. They also have <a href="http://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-082313-115826">problems understanding provider quality</a>. Shopping around, already challenging in the health care field – in case of an emergency or when there is only a limited number of providers – is hardly possible in these conditions.</p>
<h2>The recent Senate bill</h2>
<p>The most recent revision of the Senate’s Better Care Reconciliation Act makes four significant changes to HSAs and HDHPs.</p>
<p>First, it almost doubles the amount individuals are allowed to contribute, to $6,550 and $13,100 for individuals and families, respectively.</p>
<p>Second, it further increases these limits for Americans 55 and older in order to allow them to prepare for retirement.</p>
<p>Third, it also reduces the penalty individuals incur for withdrawing funds from their HSAs for nonqualified expenditures.</p>
<p>Fourth, and this is a significant departure from federal policy since the 1940s, it allows individuals and families to use money in HSAs to pay for insurance premiums. Previously, only individuals with employer-provided insurance were subject to preferential tax treatment.</p>
<h2>The rich can get richer?</h2>
<p><a href="http://www.washingtonexaminer.com/new-senate-republican-healthcare-plan-leaves-taxes-on-the-wealthy-in-place-lets-people-buy-less-expensive-plans/article/2628509">Under criticism from advocates and even members of his own party</a>, Senate Majority Leader Mitch McConnell’s (R-KY) most recently released Senate repeal-and-replace effort maintained many of the Affordable Care Act’s taxes. However, well-to-do Americans may have obtained an even better replacement in the form of Health Savings Accounts. We should also not forget that these taxes could be subject to repeal during the upcoming efforts at tax reform or the budget process.</p>
<p>We know very little about the long-term effects of high-deductible plans. However, <a href="http://content.healthaffairs.org/content/31/12/2641.full.pdf+html">scholarly findings</a> on delayed care, reduced preventive care and avoidance of medical care are cause for concern with potentially significant detrimental effects for the American health care system and Americans.</p>
<p>We also know that these arrangements further <a href="https://www.cbpp.org/research/gao-study-confirms-health-savings-accounts-primarily-benefit-high-income-individuals">segregate the risk pool and divide Americans based on their income and health status</a>. Richer and healthier individuals will seek out these plans to shelter their assets. Poorer and sicker Americans will not be able to reap these benefits.</p>
<p>More than 50 years ago, Nobel Prize-winning economist Kenneth Arrow prominently <a href="https://web.stanford.edu/%7Ejay/health_class/Readings/Lecture01/arrow.pdf">pointed out</a> that the health care field is filled with striking market failures. While HSAs and HDHP may sound like a good solution, they are unlikely, I would argue, to be viable and equitable solutions to what ails the American health care system.</p><img src="https://counter.theconversation.com/content/81013/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The latest Senate health care bill is still a hodgepodge of efforts to repeal Obamacare, critics say. One of their concerns is the focus on HSAs.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/751252017-03-24T20:02:48Z2017-03-24T20:02:48ZEssential health benefits suddenly at center of health care debate, but what are they?<figure><img src="https://images.theconversation.com/files/162385/original/image-20170324-12149-cq5bed.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Lisa Schwetschenau, who has multiple sclerosis, shown in a photo in Omaha, Nebraska on March 16. She worries that she could lose some of her essential health benefits under the new proposed health care law.</span> <span class="attribution"><span class="source">Nati Harnik/AP</span></span></figcaption></figure><p>Republicans have <a href="http://www.cnbc.com/2017/03/22/heres-why-the-gop-is-coming-up-short-on-votes-to-repeal-obamacare.html">tirelessly campaigned</a> to repeal and replace the <a href="https://www.medicaid.gov/affordable-care-act">Affordable Care Act (ACA)</a> with a conservative, market-based approach to health care. Almost seven years after its passage, and with the election of a Republican president and Congress, the ACA appeared destined to be repealed and potentially replaced. </p>
<p>The House was scheduled to but did not vote on March 24 on that replacement, the <a href="http://www.speaker.gov/HealthCare">American Health Care Act (AHCA)</a>. In the debate running up to the vote, a major sticking point was a relatively obscure, albeit important, component of the ACA called the <a href="https://www.healthcare.gov/coverage/what-marketplace-plans-cover/">Essential Health Benefit (EHB)</a> provision. </p>
<p>These benefits are those deemed “essential” by the authors of the ACA. They include maternity and newborn care, prescription drugs, emergency services and hospitalization. </p>
<p>As a public policy professor, I have studied the EHB provision, their benefits and drawbacks, and how they fit into the overarching construct of the ACA. While there may be room to improve the EHB provision, I have no doubt that outright eliminating the essential health benefits provisions of the ACA would prove to be disastrous.</p>
<h2>How the benefits came to be - and to be so loathed</h2>
<p>The provision has, together with the individual mandate, long been a bane to conservatives and libertarians. Opponents of the ACA see the EHB as restricting consumer choice and artificially inflating the cost of insurance. </p>
<p>Nonetheless, the elimination of the EHB was initially not included in the Republican efforts to repeal the ACA. Indeed, it was added only when it became clear that the Republican leadership lacked the votes to pass the AHCA because of the <a href="https://www.washingtonpost.com/news/powerpost/wp/2017/03/22/what-the-freedom-caucus-wants-in-the-gop-health-bill-and-why-they-arent-getting-it/?utm_term=.5fb1e06af28f">recalcitrance of their most conservative members</a>. </p>
<p>Prior to the ACA, it was up to each respective state to determine what benefits, called insurance mandates, had to be included in insurance plans. Not surprisingly, states differed widely in terms comprehensiveness required, and no specific benefit was deemed essential in all 50 states and Washington, D.C.</p>
<p>While most states required the <a href="https://lintvwpri.files.wordpress.com/2013/10/mandatesinthestates2011execsumm.pdf">inclusion of such benefits</a> as emergency room services (44 states), far fewer required coverage for well-child visits (32), contraceptives (30), maternity services (25), rehabilitation services (7) or prescription drugs (5).</p>
<h2>Pre-ACA requirements were weak</h2>
<p>Even when essential services requirements were in place before the ACA, they were often fairly weak and allowed insurers to make coverage optional or to cap allowable benefits. This greatly affected what and how much care people had access to. </p>
<p>For example, 62 percent of individuals in the individual market lacked maternity coverage and <a href="https://aspe.hhs.gov/basic-report/essential-health-benefits-individual-market-coverage">34 percent lacked coverage for substance abuse disorder treatment</a>.</p>
<p>Thus, the EHB provisions were included in the ACA, for many reasons. First, the <a href="https://www.medicaid.gov/affordable-care-act">ACA was intended</a> to provide coverage that offers viable protection against some of the most basic health care costs Americans experience. </p>
<p>Also, EHBs were designed to provide marketplace consumers with insurance coverage similar to the coverage of employer-sponsored insurance and Medicaid. It would not be a pared-back, bare-bones policy commonly available prior to the ACA.</p>
<p>Another goal was to empower consumers by helping them to compare different insurance plans in the insurance marketplaces. As all plans are required to provide the same basic services, insurers would be required to compete on a level playing field – and not by artificially reducing premiums by excluding essential services. </p>
<p>However, the inclusion of a minimum set of benefits also had technical reasons that are soundly based in health economics. As insurers are now required to accept all interested consumers, insurers with a more comprehensive benefit design would inevitably attract a disproportionate number of sick, and thus costly, individuals. Health economists refer to this process as <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1541-0072.2012.00446.x/abstract">adverse selection</a>. As a result, premiums for these insurers would significantly increase. In response, insurers could either adjust their benefit design or exit the market.</p>
<p>Finally, the broad set of benefits was meant to attract a large, diverse pool of consumers who would jointly share risk and cost for the services covered under the EHB. By attracting a diverse set on consumers, insurers would not be disproportionately exposed to certain high-cost individuals and the overall insurance market would be stabilized. </p>
<p>By requiring insurers to compete on price and quality – and by not allowing them to utilize benefit design to discourage individuals to sign up for their plans – sicker individuals are more evenly spread among all insurers. </p>
<h2>What would happen without them?</h2>
<p>ACA opponents have argued these requirements restrict consumer choice and artificially inflate the cost of insurance. However, eliminating the EHB provisions would likely entail a variety of negative consequences for individual consumers, insurance market, and the broader health care system. </p>
<p>The difficulty for consumers to understand and navigate the health care and insurance system is <a href="http://content.healthaffairs.org/content/22/4/147.full">well-documented</a>. The EHB guarantee consumers that a <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">certain set of basic services</a> are included in their insurance and that they are covered in case of sickness. Without EHBs, insurance plans with different benefit designs and structures would likely proliferate. The amount of information would likely overwhelm most consumers and thus make the comparison of insurance plans virtually impossible. </p>
<p>More generally, the elimination of the EHB requirement could dramatically impact insurance markets across the country. No longer required to provide a certain minimum of benefits, insurers <a href="https://www.nytimes.com/2017/03/23/upshot/late-gop-proposal-could-mean-plans-that-cover-aromatherapy-but-not-chemotherapy.html?_r=0">would successively reduce benefits</a> (a race to the skimpiest plan, if you will) in order to attract only the healthiest consumers. These people are the least likely to use services and thus prefer plans with limited protections and lower premiums. Eventually, most if not all plans would be <a href="https://www.nytimes.com/2017/03/23/upshot/late-gop-proposal-could-mean-plans-that-cover-aromatherapy-but-not-chemotherapy.html?_r=0">priced at the available tax credits</a> offered under the AHCA, because at that point these plans would essentially be free for eligible Americans.</p>
<p>As insurers move toward offering ever skimpier plans, individuals would remain free to purchase additional benefits. However, insurers could charge prohibitively high prices for these optional benefits. Or, they could be hesitant to offer these optional benefits at all, as only individuals who expect to use them would be likely to purchase them. </p>
<p>Similarly, healthy individuals could sign up for the skimpiest available insurance plans in order to fulfill the requirement to remain continuously insured. They would then expand their benefits without incurring a penalty in case they fall sick and have large health costs to cover. Or, as the AHCA premium penalties are set rather low, the healthiest individuals could completely defer obtaining such coverage until a major medical need is incurred. Again, insurers would anticipate this behavior and refuse to offer comprehensive coverage.</p>
<p>Ultimately, eliminating the EHB essentially individualizes risk and cost by shrinking the risk pool down to a single individual, a situation similar to the situation prior to the enactment of the ACA. However, health insurance works best by creating a large, diverse pool of consumers with varying health care costs. The ACA sought to achieve this goal by combining the EHB with requirements for insurers to accept all consumers and for consumers to obtain coverage or pay a fine. If people sign up only when they are sick, it raises costs and makes plans unsustainable for insurers. </p>
<h2>A need to reevaluate, not eliminate</h2>
<p>This situation would potentially be further exacerbated by Republican plans to allow for the <a href="http://khn.org/news/sounds-like-a-good-idea-selling-insurance-across-state-lines/">selling of insurance across state lines</a>. Even if liberal states like California were to maintain similar consumer protections as present in the ACA, it is conceivable, even likely, that more conservative states like Florida would quickly move in the opposite direction. That is, they would allow for the sale of so-called bare-bones plans with few benefits or catastrophic plans – plans that only offer protection in case of significant financial exposure. </p>
<p>Both types of plans would naturally be less expensive compared to the more comprehensive plans, and thus attract the healthiest individuals. This has the potential of triggering a death spiral in the insurance markets of more protective states as their premiums would would skyrocket. </p>
<p>As such, individual consumers would bear significant hardship due to the elimination of the EHB. More limited coverage will inevitably lead to higher out-of-pocket costs for consumers.</p>
<p>The negative effects would likely be compounded for the broader health care system. Hospitals will be subject to increasing uncompensated care costs and will then shift these costs either to other consumers or be forced to close their doors. Also, a lot of the benefits of prevention and early intervention would likely be lost.</p>
<p>The EHBs have undeniably <a href="http://www.heritage.org/health-care-reform/report/obamacare-and-insurance-benefit-mandates-raising-premiums-and-reducing">raised insurance premiums</a>. However, this is hardly surprising because they have done so by reducing out-of-pocket costs and by providing consumers with <a href="https://www.nytimes.com/2016/04/21/upshot/obamacare-seems-to-be-reducing-peoples-medical-debt.html">meaningful protection against the vagaries of sickness</a>. </p>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">In my own work</a>, I have shown the diverse approaches that states have taken to adapt the EHB to their local health insurance markets. Unfortunately, <a href="http://gradworks.umi.com/10/16/10164660.html">I have also shown</a> that states often do not rely on available policy expertise to balance adequate coverage with affordability. </p>
<p>Considering the benefits of EHBs, it would be prudent for all stakeholders to continuously revisit the important question of what services should be included in the EHB and which ones should not.</p><img src="https://counter.theconversation.com/content/75125/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Essential health benefits under Obamacare are suddenly the center of controversy in the proposed replacement bill. If certain health benefits are so essential, why are they so loathed? Here’s a look.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/719672017-02-09T03:50:08Z2017-02-09T03:50:08ZHow Democrats can help Trump make the ACA’s replacement ‘terrific’<p>One of the <a href="https://www.nytimes.com/2017/01/10/us/repeal-affordable-care-act-donald-trump.html?_r=0">top priorities</a> of the Republican-led Congress and the Trump administration is repealing and replacing the Affordable Care Act (ACA), President Barack Obama’s landmark health care law. </p>
<p>Even <a href="http://www.huffingtonpost.com/entry/how-obama-would-fix-obamacare_us_56bcd8d6e4b0c3c550506e19">supporters of the ACA</a> want to repair its flaws, such as a lack of competition in some state insurance marketplaces. But because the ACA has also made major improvements to the health sector, it will be very difficult to craft a replacement that doesn’t disrupt insurance markets or increase the ranks of the uninsured. </p>
<p>During the campaign, President Donald Trump <a href="http://thehill.com/policy/healthcare/249697-trump-replace-obamacare-with-something-terrific">promised</a> that the ACA’s successor will be “terrific,” an adjective that may have reassured some voters. After all, except for the individual mandate to purchase insurance, most parts of the ACA are <a href="http://kff.org/health-reform/press-release/after-the-election-the-public-remains-sharply-divided-on-future-of-the-affordable-care-act/">popular with the public</a>. </p>
<p>But the word “terrific” also hints at the best way Democrats can influence the revision of the ACA, as well as ensure that any problems that emerge can be fixed by Congress. </p>
<h2>The ACA’s results</h2>
<p>In many respects, the ACA has been a success. </p>
<p>Last December, the Obama administration’s Council of Economic Advisers released a long <a href="https://www.whitehouse.gov/blog/2016/12/13/economic-record-obama-administration-reforming-health-care-system">report</a> that extensively documented the positive effects of the ACA. That’s an assessment backed up by <a href="https://theconversation.com/love-it-or-hate-it-obamacare-has-expanded-coverage-for-millions-66472">independent experts</a>, such as the <a href="http://kff.org/uninsured/report/the-uninsured-a-primer-key-facts-about-health-insurance-and-the-uninsured-in-the-wake-of-national-health-reform/">Kaiser Family Foundation</a>.</p>
<p>Few people know, however, that the Obama administration established <a href="https://www.hhs.gov/sites/default/files/fy2017-performance-plan_remediated.pdf">official goals for the ACA</a> and reported data on how well those goals were met.</p>
<p>This was required under the <a href="http://www.gpo.gov/fdsys/pkg/BILLS-111hr2142enr/pdf/BILLS-111hr2142enr.pdf">GPRA Modernization Act</a> (GPRAMA), which was passed in 2010 to improve the 1993 Government Performance and Results Act (GPRA). </p>
<p>The 1993 law required departments to prepare strategic plans and report on performance. This helped the executive branch measure results and manage operations, but it did not encourage coordination over goals that crossed jurisdictional boundaries. </p>
<p>Congress crafted GPRAMA to reduce that problem by formalizing mechanisms for better coordination. And so now the executive branch must declare its priority goals across all major departments, and their leaders must hold quarterly reviews of the extent of <a href="http://performance.gov">progress toward those goals</a>. </p>
<p>Some of the goals the Obama administration set for the health sector included how many people it aimed to enroll in the new health insurance marketplaces, the share of the non-elderly population still uninsured and hospital readmission rates.</p>
<p>As one example, the Health and Human Services Department wanted to get 10 million people enrolled in ACA health insurance marketplaces in 2016, up from its target of 9 million the year before. In March 2016, the department <a href="https://aspe.hhs.gov/sites/default/files/pdf/187866/Finalenrollment2016.pdf">reported</a> that it had surpassed its goal by 2.7 million. (This doesn’t count the additional millions who received insurance through the expansion of Medicaid.)</p>
<h2>The Byrd rule roadblock</h2>
<p>While Republicans are eager to ax the ACA – having voted in the House <a href="http://www.reuters.com/article/us-usa-obamacare-idUSKBN14X1SK">more than 60 times</a> to do so – they <a href="http://www.vox.com/policy-and-politics/2017/1/27/14417272/republicans-obamacare-secret-tape-leak">seem flummoxed</a> about how to proceed with its replacement. </p>
<p>The House GOP’s 2016 “A Better Way” plan for <a href="https://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-PolicyPaper.pdf">health care</a> promised generally to “provide all Americans with more choices, lower costs and greater flexibility.” It proposed many changes to the ACA, but – unlike the Obama administration’s targets – did not specify any expected outcomes from their plan.</p>
<p>Some Republican health policy experts who oppose the ACA <a href="http://healthaffairs.org/blog/2017/01/03/the-problems-with-repeal-and-delay/">recently warned</a> that repealing the law but delaying a replacement would disrupt insurance markets. Democratic defenders of the law <a href="https://www.brookings.edu/opinions/why-republicans-cant-and-wont-repeal-obamacare/?utm_campaign=Economic+Studies&utm_source=hs_email&utm_medium=email&utm_content=41255242">argue</a>, with much logic, that it will be very hard to develop better alternatives to most of the ACA’s <a href="http://kff.org/health-reform/press-release/after-the-election-the-public-remains-sharply-divided-on-future-of-the-affordable-care-act/">popular provisions</a>, such as free preventive services and the prohibition against excluding people with preexisting conditions from coverage.</p>
<p>In January, the GOP took a first step toward repealing the ACA, passing a fiscal year 2017 budget resolution that aims to “fast-track” the process by instructing committees to <a href="http://budget.house.gov/UploadedFiles/Final_FY17_Budget_Resolution_1_page_Summary.pdf">use a budget procedure</a> known as “reconciliation.” In the modern Senate, because the minority can threaten a filibuster, it takes 60 votes to pass important bills. Reconciliation, in contrast, requires only a simple majority.</p>
<p>Democrats themselves used reconciliation in 2010 to pass part of the ACA after they lost their 60-vote majority.</p>
<p>But there is a limit to how Republicans can use reconciliation to get around Democratic objections. Reconciliation bills must comply with the <a href="https://fas.org/sgp/crs/misc/RL30862.pdf">Byrd rule</a>, a three-decade old Senate rule. </p>
<p>Like many Senate rules, the Byrd rule is complicated enough that the Senate parliamentarian will be called upon to interpret what it allows and what it does not. Primarily, it aims to ensure reconciliation bills are budgetary in nature by affecting spending or revenue. But one of its elements also says that provisions with a different purpose from the bill in question – such as, in the ACA repeal’s case, killing a health care regulation – have to be excluded. And since the health sector is very complex, any effort to repeal and replace the ACA would have many provisions that would be prohibited by the Byrd rule.</p>
<p>This means that at least part of any attempt to repeal and replace the ACA will have to go through regular legislative procedure, allowing Democrats to amend the proposed bill. </p>
<p>One caveat: It’s possible that Republicans will simply nix the Byrd rule, similar to how <a href="http://www.politifact.com/truth-o-meter/article/2017/feb/03/6-questions-answered-about-nuclear-option-filibust/">they’re considering “going nuclear”</a> by getting rid of the Senate filibuster for Supreme Court nominations. But let’s assume for the moment that they don’t.</p>
<h2>Making the ACA replacement ‘terrific’</h2>
<p>This procedural roadblock is what creates the opportunity for Democrats to insist that a replacement of the ACA be, in fact, “terrific.” </p>
<p>In the Senate, Democrats could propose amendments to a replacement bill that would set specific goals of access, cost and quality – essentially requiring Trump to take responsibility for his promises that the replacement will be, <a href="https://www.washingtonpost.com/politics/trump-vows-insurance-for-everybody-in-obamacare-replacement-plan/2017/01/15/5f2b1e18-db5d-11e6-ad42-f3375f271c9c_story.html">in his words</a>, “insurance for everybody.” </p>
<p>Following a <a href="http://healthaffairs.org/blog/2017/01/17/first-do-no-harm-a-physician-secretary-of-hhs-and-the-reach-of-hippocrates/">“first do no harm”</a> principle, these goals could be based on projected levels under current law.</p>
<p>After many years of vociferously criticizing the ACA, Republicans should be willing to be held accountable for the results of repealing and replacing it. </p>
<h2>A third ‘R’: Repeal, replace and revise</h2>
<p>The new law should also set up a process for reviewing attainment of those goals and for revising the law if it turns out to be flawed.</p>
<p>When Congress considers a replacement for the ACA, the nonpartisan Congressional Budget Office <a href="https://www.nytimes.com/2017/01/10/opinion/seven-questions-about-health-reform.html?emc=eta1">will project</a> the new law’s likely effects. But given the complexity of the health sector, even projections from these expert analysts will inevitably be <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/dec/cbo-crystal-ball-forecast-aca">wrong</a>. </p>
<p>So though repeal and replacement will be a stressful experience, Congress should not then expect years of rest and relaxation. In order to conduct oversight on the transition to a new health system, Congress should insist that the Trump administration declare goals, conduct quarterly reviews of results and report on its performance to Congress and the public. </p>
<p>To reassure the <a href="http://www.usnews.com/news/articles/2017-01-06/poll-on-obamacare-americans-want-to-see-replacement-before-repeal">many people worried</a> about the GOP’s “cure” being worse than the disease, Congress could also promise – in the repeal-and-replace legislation – to hold votes on revising the law during the next session of Congress, which begins in 2019. That is, if a provision is found to come up short of its goals or desperately needs revision, there would be a fast-track process to fix any problem or revert to the ACA original. </p>
<p>While including this process would not amount to an ironclad promise – because the majority can effectively determine the rules for each Congress – it would be a commitment that would be broken only in bad faith.</p>
<h2>Repair with results</h2>
<p>Some revision of the ACA is inevitable and even desirable. </p>
<p>If Democrats and Republicans jointly agree on establishing specific goals for the reform, building on the existing process for monitoring attainment of those targets, it could lead to measurable improvements in the health system. In doing so, the “repeal and replace” campaign slogan could be transformed into “repair with results.”</p>
<p>The alternative could be attractive to politicians who wish to avoid responsibility for their actions. However, many negative outcomes from the new system will be more than obvious to the patients who lack quality health insurance. </p>
<p>If that happens, they won’t be tweeting the word “terrific.” Instead they will more likely to be “SAD!” and “MAD!”</p><img src="https://counter.theconversation.com/content/71967/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Roy T. Meyers does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A 2010 law that requires the executive branch to set goals and an obscure Senate rule may be the Democrats’ best chance to influence GOP plans to repeal and replace Obamacare.Roy T. Meyers, Professor of Political Science and Affiliate Professor of Public Policy, University of Maryland, Baltimore CountyLicensed as Creative Commons – attribution, no derivatives.