Wednesday, February 01, 2017

Repair, not replace -- rebranding, or real change? Watch the Medicaid expansion

The battle over ACA repeal-or-whatever is going to go through a lot of twists and turns and bold assertions that will fade like morning dew. Still, the latest Republican messaging and positioning seems at least potentially significant. From The Hill's Peter Sullivan:
Key Republican lawmakers are shifting their goal on ObamaCare from repealing and replacing the law to the more modest goal of repairing it...

“I'm trying to be accurate on this that there are some of these provisions in the law that probably will stay, or we may modify them, but we're going to fix things, we're going to repair things,” House Energy and Commerce Committee Chairman Greg Walden (R-Ore.), a key player on healthcare, told reporters Tuesday.

“There are things we can build on and repair, there are things we can completely repeal,” he said.

Senate Health Committee Chairman Lamar Alexander   (R-Tenn.) is sounding a similar note....

“I think it is more accurate to say repair ObamaCare because, for example, in the reconciliation procedure that we have in the Senate, we can't repeal all of ObamaCare,” Alexander said. “ObamaCare wasn't passed by reconciliation, it can't be repealed by reconciliation. So we can repair the individual market, which is a good place to start."
First reaction is: careful! This sounds on its face more like rebranding than rethinking. It leaves space for gutting the law's funding and sunsetting its core provisions via reconciliation.

The really significant reporting comes a bit deeper in: Republicans are seriously split about repealing the Medicaid expansion:
There is a split within Republicans over what to do about ObamaCare’s Medicaid expansion, which provided coverage to about 11 million new low-income people. Lawmakers from the 31 states that accepted the expansion are more likely to want to protect the expansion and the federal money for their states that came with it.

he Senate is taking a much slower pace than the House when it comes to ObamaCare — partly because of questions over how to handle the Medicaid expansion.

Sen. John Hoeven (R-N.D.), whose state accepted the expansion, said that he wants to keep it while providing more flexibility to states to make changes to the rules of the program, a common Republican goal.

“I think we should keep the Medicaid expansion, but we have to modify it to give the states more control so that they can manage it in a way that works in their state,” Hoeven said.

Even in the House, Walden acknowledged that some sort of compromise would have to be worked out around Medicaid expansion before Republicans would have enough votes to pass a repeal bill. 
Preserving the expansion, as I've argued before, would actually do more for more lives than avoiding a remake of the individual market for health insurance.  If active citizens and Democrats in Congress manage to salvage the expansion, that's huge.

On the other hand, Sullivan sees a propensity of power among Republicans in favor of repealing the ACA taxes that largely fund the benefits. And that cuts against genuinely saving the expansion -- as opposed, perhaps, to bleeding it dry more or less quickly over ten years.

Bulletin to Republicans: you can't insta-repeal the ACA's taxes and preserve the Medicaid expansion -- or the ACA's coverage gains more broadly -- in any meaningful sense. Rejigger coverage rules if you must -- break the ACA's fingers. But don't disembowel it.

One more meta-message here: public pressure is working. It's making a lot of Republican senators think twice about sating their bloodlust to cut taxes and gut benefits. The longer they delay, the more they fragment, and the less damage they're likely to do.

On the other hand, paralysis -- or Bannon-style bomb-dropping from the executive branch -- could collapse the individual market while Congress...deliberates. In which case, it's all-out blame war.

Oh, and one last footnote: note Alexander casually acknowledging that the ACA wasn't passed by reconciliation.  Remember Republicans' relentless gaslighting on that score? Never mind.
UPDATE, 2/2: A Washington Post article by Amy Goldstein throws into sharp relief the Republican split between Orrin Hatch, who's hot to insta-repeal the ACA's taxes and so disable any real "replacement," and Lamar Alexander, who wants to preserve the Medicaid expansion:
Alexander also signaled that he might be receptive to taking a smaller first step than President Trump and many Republicans favor. “Is it possible to work just on the individual market?” he asked, referring to the ACA marketplaces intended for people without access to affordable health benefits through a job. He suggested that Congress might “leave for a separate discussion” the idea of transforming Medicaid and Medicare so that they are no longer entitlement programs.
Meanwhile, the article's lead shows insurers warning warning Republicans to either shore up the individual market for 2018 -- at a minimum, assure that premium subsidies and CSR will remain in place -- or expect market collapse. 

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