By Jill Zorn
With passage of the massive tax giveaway bill this past weekend, Congressional Republicans are making good on their promise to repeal the Affordable Care Act (ACA) – something they failed to do all year despite repeated attempts.
After the inauguration of Donald Trump in January, health care advocates thought that repeal of the ACA would be just a few months away. We came up with a rallying cry early on, “No repeal without replace”. This proved to be an important part of the strategy to combat repeal, because Congressional leaders and the president never actually had a workable idea for how to restructure health coverage if they killed the ACA. Despite some flip-flopping by President Trump, Republicans seemed to buy in to the idea that they couldn’t repeal now and replace later-they would have to have an actual replacement plan in place.
Through the roller coaster ride of four Republican efforts to repeal the ACA this year, it was the replace part of the equation that always eluded them – they had no answers for what would happen to the millions of people losing coverage.
But a few weeks ago, as the tax bill was moving forward, the Senate decided to add repealing the individual mandate of the ACA into the bill – a provision not included in the House version of the bill. With this action, the Senate was trying to have their cake (massive tax cuts for corporations, millionaires and billionaires) and eat it (take away an important pillar of the ACA), too.
By eliminating the mandate, Republicans “save” $338 billion, helping to keep the $1.4 trillion deficit caused by their proposed tax cuts from being even higher. But those savings occur because an estimated 13 million Americans will no longer have health coverage, including 5 million on Medicaid. As Sarah Kliff of Vox puts it, the Senate tax bill may be the start of ACA collapse.
What Happened to Senators That Voted No on Previous Repeal Votes?
The few Republican Senators who had fallen on their swords to protect the ACA during previous repeal fights melted away this time– Senators Murkowski, McCain and Collins all voted for the tax bill. Senator Murkowski, never a fan of the individual mandate, appears to have sold her vote for a provision in the bill that allows oil drilling in the Arctic National Wildlife Refuge. Senator McCain supported the hastily written bill that had many last-minute, even hand-written provisions, by claiming that the process had sufficiently followed regular order to earn his vote.
Senator Collins handed over her vote for “assurances” that two bills intended to help stabilize the insurance market will pass and for a letter signed by Senate Majority Leader Mitch McConnell promising that Medicare will be protected from an automatic $25 billion spending cut (due to a previous law that requires spending cuts to offset revenue cuts).
But there is no way to guarantee these commitments will be honored. The bills Collins would like to see passed would fund Cost Sharing Reduction (CSR) payments and provide extra funding for reinsurance, to help insurers cover the costs of caring for very sick enrollees with high health care expenses.
But these positive steps are not likely to stabilize insurance markets sufficiently to mitigate the damage caused by the withdrawal of the individual mandate. And as one Slate commentator speculated about the promise to prevent automatic Medicare cuts, “Perhaps Collins could use the letter as tinder to get her fireplace going when she returns to the Maine winter?”
Unless the House rolls over and passes the Senate bill, the bill is headed to a conference committee to hammer out a version that both houses of Congress can agree on. Meanwhile, advocates are gearing up for a full week of protest. Among the targets are vulnerable House members, several deficit-hawk Senators and Senator Collins, who says her vote is not guaranteed until she sees what comes out of the conference committee.
One other wild card is that, in the middle of all of this turmoil, Congress must pass a continuing resolution on December 8 to keep the government funded – action that will require 60 affirmative votes in the Senate. This vote, which could be postponed until the end of the year, may be the last opportunity for Democrats to fix some other health care priorities, like approving funding of the Children’s Health Insurance Program (CHIP) and community health centers. This may also be a crucial opportunity to protect against the $25 billion automatic Medicare cuts and renew the DACA program to prevent deportation of up to 800,000 young immigrants.
So, fasten your seat belts. This roller coaster ride isn’t over yet.