The health insurance "who pays?" tug-of-war

If you're going to cut a string to a certain length, whichever end you cut, you'll still have the same length.

The first substantive "repeal and replace" legislative proposal offered by Republicans since the ACA passed, unveiled in outline on January 27 by Republican Sens. Tom Coburn (OK), Richard Burr (NC), and Orrin Hatch (UT), illustrates that basic principle on multiple fronts. That's because its core provisions are to greater or lesser degrees cousins of their counterparts in the ACA.

As Don Taylor has been pointing out for a week, the rollout of the Coburn-Burr-Hatch  proposal last Monday highlights the fact that any real attempt to replace the ACA while at least roughly matching its coverage goals will expose the GOP to the same kinds of attacks -- perhaps more from their right wing than from the Democrats -- as they've been leveling at Democrats since the ACA took shape in 2009. 

In some cases, the choices advanced in Coburn et al's so-called Patient CARE Act (following Taylor, I'll call it PCARE) may represent improvements over parallel provisions in the ACA. But all such choices involve tradeoffs -- alternate plans will have, to varying degree different winners and losers  (high taxpayers vs. subsidized insureds; young vs. old; employer-insured vs. individual market-insured; healthy vs. sick).  Many if not most of us will be on different sides of each of these divides at different points.

One feature of PCARE, or rather two interrelating features, throw the nature of these tradeoffs into relief. For years, Republicans have been screaming that the ACA forces young adults in the individual market to subsidize older participants. That's because the ACA limits the allowable extent to which the oldest participants can be charged more than the youngest to a 3-to-1 ratio, whereas pre-ACA, most states allowed ratios of  5-to-1 or more (42 states, according to AHIP). That alleged bilking of the young was at the heart of the case against the ACA's constitutionality argued in the Supreme Court in March 2012 and fueled all the cries of "rate shock" from conservative critics of the ACA in 2013. According to the Kaiser Family Foundation, the impact of the narrower age banding on young adults' premiums is pretty modest, but never mind.