At times, various factions in Congress have called for repealing, replacing, or repairing Obamacare. Senate Republicans have been unable to agree on which of these ends to pursue, and so instead they are driving toward a policy that would, astonishingly, do none of them. The new plan is what they call a “skinny bill,” which would eliminate the employer and individual mandate and a tax on device makers. The only coherent end it serves, and the only way to understand this bizarre idea, is as the latest expression of the party’s years-long quest to avoid having to define a health-care plan.
The skinny bill, taken on its own terms, would leave the vast majority of Obamacare in place. The expansion of Medicaid would be untouched, as would its regulations on insurance and tax credits to make insurance affordable. Eliminating the individual mandate, though, would do severe damage to the exchanges. People could go without insurance, and then choose to buy in when they need medical care, which would drive up the cost of premiums.
Before Obamacare, a handful of states tried to regulate insurance to prohibit discrimination against people with preexisting conditions. But doing this without subsidies and an individual mandate simply drove healthy people out of the markets and created a death spiral. Analysts on the right and the left alike concluded these experiments were a failure. Conservatives have proposed various alternatives to the individual mandate, but the “skinny bill” does not contain any of these. It simply eliminates an important function of the current law.
It’s not clear whether the skinny bill would melt down the individual market altogether. There’s not much study of this as a stand-alone policy, mainly because it’s a terrible idea nobody has ever thought to propose, and Republicans came up with it just this week in a mad rush. The tax credits in Obamacare might create a stable-enough customer base. (Low-income consumers can get insurance for free, so they have no reason to skip out until they’re sick.) And some states, prodded by nervous insurers, might create a state-level mandate to replace the disappearing federal one. But it is clear that the skinny bill would damage the markets and increase premiums while advancing no coherent policy objective.
The point, rather, is to reduce the repeal agenda to its most popular constituent elements, pass something that 50 Republicans can live with, and then create a chance to go to conference with the House and rewrite the proposal. Republicans are very clear about their belief that the skinny plan is not intended to be passed into law. “If we can get a skinny bill over (to the House), we can work in the conference committee to actually improve on the product,” South Dakota Republican senator Mike Rounds told reporters. The “content” of the bill is not the point, says Senator Bob Corker, who calls it a “forcing mechanism.”
But what would the conference bill actually do? Nobody is saying, probably because they have no real idea. Republicans are no closer to solving the problem of designing an Obamacare replacement now than they were when the Senate began its debate weeks ago. Indeed, they’re no closer now than they were when the health-care debate began in 2009.
The GOP’s failure to cohere around a proposal is not an incidental problem. It is a fundamental and unsolvable one. Conservative dogma is wholly incompatible with the development of any health-care plan that is remotely acceptable to the public. The only solution in the face of this dilemma is to denounce Obamacare while promising something different and better to come along at a later date.
The Republican Party has stuck to the strategic imperative of putting off its plan as unswervingly as the Russian empire pursued its goal of securing a warm water port. It is why Republicans never developed an alternative during the health-care debate that might have peeled away moderate Democrats. It is why their years of repeal votes always promised a replacement to come later. It is why their first and best plan after Trump’s election handed them power was a two-stage “repeal and delay.”
The alternative to this endless farce is to admit the process of developing a Republican-only repeal and replace of Obamacare is a failure. It would be easy, almost trivially easy, to patch up the law and bring down premium costs — simply halting deliberate sabotage by the Trump administration would be enough. But this would admit that the party has spent eight years making promises that it could not fulfill. And a liar who is caught usually prefers to delay exposure as long as possible.