In one of the better lines in last night's State of the Union address, President Obama chided House Republicans for their endless series of votes to repeal the Affordable Care Act: "[L]et's not have another 40-something votes to repeal a law that's already helping millions of Americans ... The first 40 were plenty." He followed up by observing that "we all owe it to the American people to say what we're for, not just what we're against." As it happens, last week three Republican senators outlined a plan that can be fairly described as a Republican plan to replace Obamacare. (The basic features of the plan are clearly described by Sarah Kliff of Wonkblog here.) Because most of the Republican Party convinced themselves in 2009 that a tax penalty for people who don't carry health insurance was a grave threat to the American constitutional order, the plan does not include an individual mandate. But otherwise, in its general priorities the plan strongly resembles the Heritage Plan of the late 1980s. That is, it's radically different than the ACA, and it's horrible, immoral public policy.
In fairness, the RIchard Burr-Tom Coburn-Orrin Hatch proposal does maintain some of the salutary features of the ACA. Parents will be able to maintain coverage for their children until age 26 (although states would be able to opt out of this provision). Insurance companies would be banned from imposing lifetime limits on benefits, and the ban on the rescission of insurance except in cases of fraud or misrepresentation would be maintained in at least some form. Even conservative Republicans are no longer willing to explicitly oppose some of the consumer protections and the core of the ACA.
But the differences between the Republican proposal and the ACA are great, and they involve denying exactly the rights and benefits that Obama highlighted during the State of the Union.
"And here's another number: zero. Because of this law, no American, none, zero, can ever again be dropped or denied coverage for a pre-existing condition like asthma or back pain or cancer."
The Burr-Coburn-Hatch proposal would repeal the ACA's guaranteed coverage. In many cases, insurance companies would be able to deny people insurance based on pre-existing conditions. The plan would protect people who have been continuously insured for 18 months. But if you've never had health insurance? You're out of luck. If you've lost health insurance at some point in the last year and a half or haven't had it at all because you've lost your job? You're out of luck. The plan would offer a narrow one-time only enrollment period for those with pre-existing conditions, but anyone who missed that narrow window would not be guaranteed the ability to purchase insurance that contained the continuous coverage protections. This change is a classic illustration of Republican priorities: more protection for corporate interests, much less protection for consumers.
"No woman can ever be charged more just because she's a woman."
The Burr-Coburn-Hatch proposal would eliminate the ACA's gender equity provisions—not exactly a shock coming from the party of Todd Akin and mandatory ultrasounds. This difference illustrates another crucial difference between the ACA and the Republican alternative. The ACA contains numerous important consumer protections, such as requirements that private insurers to cover things like contraception and routine doctor visits and limits on the total amount that an individual would have to pay out of pocket in a given year. The Republican plan would eliminate most of these protections, making the individual insurance market somewhere between "dubious" and "a con."
"For decades, few things exposed hard-working families to economic hardship more than a broken health care system. And in case you haven't heard, we're in the process of fixing that."
The American health care system is broken for many reasons, but perhaps the most important is the tens of millions of people who lack health insurance. The ACA addresses this in a multitude of ways, one of which is to provide subsidies to those who earn too much to be eligible for Medicaid but not enough to afford decent private insurance. Burr-Coburn-Hatch would make these subsidies substantially less generous for those who receive them, while eliminating them entirely for many non-affluent working people.
"And if you want to know the real impact this law is having, just talk to Governor Steve Beshear of Kentucky, who's here tonight."
Obama cited Beshear because he's one of the few red-state governors to accept the Medicaid expansion offered by the ACA. The Medicaid expansion of the ACA is perhaps the most important achievement of the ACA, greatly expanding health coverage to the working poor. The Republican plan would undo most of this progress, eliminating both the requirement raising Mediciad eligibility to 138 percent of the federal poverty line and the requirement that all individuals within this window (rather than a relatively small subset) be eligible. It would also eliminate the increases in Medicaid payments to physicians that will make medical care more accessible to Medicaid recipients. What the Republicans offer instead is the familiar conservative refrain justifying opposition to social progress: let them eat states's rights. Rather than the expanded eligibility of the ACA, Burr-Coburn-Hatch would just give states a fixed amount of money per head reflecting the eligibility standards of a given state (which in the majority of cases would be much less expansive than the ACA's standard.)
In the current political context, the idea that giving more autonomy to the states is a magic formula that will lead to more efficient health care coverage for the working poor is particularly absurd. The Supreme Court's unfortunate decision to invent new doctrine and strike down the funding mechanism that would have made a 50-state Medicaid expansion likely provides a natural experiment revealing how serious Republican governors in red states are about covering the working poor. The results are in: most conservatives at the state level would rather leave huge amounts of money on the table than increase health care access for the working poor. The assumption that giving the states less money with many fewer strings attached would in itself result in superior coverage for the working poor is a cruel farce.
And yet, using this awful proposal as the baseline for Republican health care policy is probably too charitable. History suggests that absent the need to pretend to have an alternative to the status quo the Republican proposal for reform is non-existent. But even if one assumes that this proposal is in good faith, it shows Republicans treating those without access to decent medical care the same way they're increasingly treating the unemployed and those who can't afford to put food on the table: with callous indifference.