Just when you thought the congressional saga over repealing and/or replacing Obamacare could not get any stranger, there’s a new twist at the end of the road for the Senate that could apparently represent Mitch McConnell’s last-gasp effort to enact something: a “skinny repeal” of Obamacare (a term that appears to have been invented today, in keeping with the whole “surprise! surprise!” nature of the process). With passage of a motion to begin debate of health-care legislation now complete, “skinny repeal” could represent the way out of what earlier appeared to be an impasse among Senate Republicans.
The idea, for all its procedural complexity, is simple enough: At the end of the required 20 hours of Senate debate, and after a required “vote-a-rama” over what is likely to be a long list of amendments, if Senate Republicans fail to enact some version of a “straight repeal” of Obamacare or some version of the Better Care Reconciliation Act, Mitch McConnell will offer a stripped-down substitute – i.e. the skinny repeal – that does just enough to attract 50 votes. The bill will then move to a House-Senate conference, where the real deal would go down.
A skinny repeal would definitely include a repeal of the Obamacare individual mandate — taking down a provision all Republicans purport to hate — and maybe the employer mandate, while repealing some of the Obamacare taxes. It would meet the underlying budget resolution’s deficit-reduction requirements because killing the mandate would significantly (by a net figure of $416 billion over ten years, according to a 2016 CBO estimate) reduce the number of people applying for and receiving Obamacare insurance-purchasing tax credits. More importantly, a skinny repeal would avoid — or at least defer — virtually all the issues Republicans have been fighting over: the Medicaid expansion, Medicaid per capita caps, insurer subsidies, premium changes, mandated health benefits, the Cruz amendment, Planned Parenthood de-funding — you name it. And of equal importance, it would buy time for Republicans to deal with the various procedural road-blocks the Senate parliamentarian has thrown in their path on various must-pass provisions.
The biggest single problem with skinny repeal — other than the fact that nobody’s mentioned, much less debated it, before right now — is that it will place senators voting for it on record as favoring legislation that if actually enacted would create insane havoc in insurance markets. As Vox’s explainer puts it:
Repealing the individual mandate risks sending Obamacare’s insurance markets into a death spiral. Health insurers have long said that a compulsion for people to buy insurance is necessary in order for the law to work, after it required that insurers cover everyone and charge everyone the same premiums no matter their health.
Without such a mandate, healthy people could forgo coverage while sick people would continue to buy insurance, driving up costs for insurers, who in turn increase premiums, sending the market into a death spiral. The Congressional Budget Office estimated repealing the mandate by itself would lead to 15 million fewer Americans having health insurance 10 years from now.
And that’s without even considering how insurers thinking about 2018 rates right now might react; “We’ll take care of it in conference” isn’t a very reliable assurance for businesspeople.
Crazy as it may seem at this late date, there is a certain twisted logic to a skinny repeal: Throughout the first half of 2017, every time Republicans have been confronted with the basic unpopularity of repealing and replacing Obamacare, they’ve promised themselves the bill will be improved somewhere down the line. This would be the ultimate act of kicking the can down the road. And the provisions individual GOP members of Congress wanted in the final bill — the Cruz amendment (permitting cheap, skimpy policies), more money for Medicaid, more repealed taxes, less regulation — could be envisioned as magically appearing once the House and Senate have conferred. For McConnell, Paul Ryan, and Donald Trump, however, it would mean the GOP has gotten very close to “keeping its promise” to get rid of Obamacare. And the calculation may be that warring Republicans won’t dare raise objections when the goal of taking down the Great White Whale of Obamacare is so close to achievement.
It’s also fitting that in just 24 hours Republicans have gone from a scenario in which the House would simply rubber-stamp whatever the Senate passed without a conference, to one in which the Senate passes nothing other than the total empowerment of a House-Senate conference to resolve everything. If the skinny repeal actually happens, the GOP’s lack of unity and vision on health-care policy — and its willingness to buy a giant pig in a poke — will have reached its ultimate, nihilistic peak.
