The Transom, Ben Domenech, June 23, 2017

Longtime readers know I have repeatedly expressed my skepticism about the AHCA and its approach to health care policy, both as an ideological matter and with concerns about its workability as an approach. That said, the Senate bill that dropped yesterday seems to be an improvement on some of the AHCA’s obvious defects.  For a straight-up view of what’s inside, with links to the comparisons between versions, here’s Chris Jacobs. Of note:  “In the absence of a complete bill and Congressional Budget Office (CBO) score, it is entirely possible the parliamentarian has not fully vetted this draft—which means provisions could change substantially, or even get stricken from the bill, due to procedural concerns as the process moves forward.”

In the positive camp, we have Avik Roy.  “There were great things about the House bill, in particular its far-reaching reforms of the Medicaid program. But Paul Ryan’s bill contained a fatal flaw. Its flat tax credits, which provided identical assistance to the poor and the wealthy, would price millions of near-elderly low-income workers out of the insurance market and trap millions more in poverty.

“Fortunately, buried in the House bill was a way out of the morass. Section 202 of the bill contains a transitional schedule of tax credits that was meant to serve as a bridge between the old Obamacare system, ending in 2017, and the new Paul Ryan system, beginning in 2020.

“It turns out that if you simply kept that bridge in force, and tossed overboard the Paul Ryan flat tax credit, you’d solve all of these problems with the House bill. By making that change, the near-elderly working poor would be able to afford coverage, and the poverty trap would be eliminated.

“And that’s precisely what the Senate bill did! Section 102 of the Senate bill—the Better Care Reconciliation Act of 2017—closely mirrors Section 202 of the House bill, with age- and means-tested tax credits up to 350 percent of the Federal Poverty Level. Making this change not only solves the problems I described above. It also makes it easier to reform the Medicaid program.”

In the negative camp, Peter Suderman, who describes it as Obamacare lite.  “Like the House plan, the Senate plan retains Obamacare’s major insurance regulations, including the requirement to cover pre-existing conditions, at the federal level. Unlike the House plan, it does not allow states to apply for a waiver to opt out of those rules. It also eliminates Obamacare’s health insurance mandate.

“Every state that has attempted this combination of coverage regulations without a mandate has seen a swift meltdown in the individual market. There is every reason to expect that the same would happen under the Senate plan, especially since Obamacare’s exchanges were struggling with a too-small, too-sick enrollee pool even with the mandate in place.

“The Senate bill attempts to manage this instability by buying off health insurance companies with payments that Republicans previously argued were illegal and should be stopped.

“The way it does this is by authorizing additional payments known as cost-sharing reduction (CSR) subsidies to insurers through 2019. It also authorizes the back payment of any CSR subsidies that insurers have not recieved. On this front, it is actually an expansion of Obamacare, and it is a revealing sign of the shallowness of Republican thinking on health care policy.”

In the middle camp, David Harsanyi.   “Majority Leader Mitch McConnell has finally revealed the specifics of Republicans’ “secret” health-care bill — “Better Care” — and, reportedly, he wants a vote by next week. Senators Rand Paul, Ted Cruz, Ron Johnson, and Mike Lee all say they will oppose the bill as written. There’s a chance they’ll be joined by some moderates who feel reluctant to trim Medicaid. At this point, it feels like most of them want to get to yes and are posturing for concessions. Or maybe the entire debate is a giant kabuki dance for voters, and nothing will pass.

“Whatever the case, Republicans should ask themselves what the alternative looks like. Listen, I wish Mike Lee were writing a market-based Obamacare repeal bill and that we had a president who was interested in reforming welfare, but at some point conservatives are going to have to take a page from Democrats and occasionally embrace incrementalism. Idealism is empowering and necessary. Yet pragmatism can’t always be treated as a transgression. You’re going to see the bill change — provisions in the bill might need to be altered once we get a Congressional Budget Office score and the parliamentarian vets it — but you’re not going to see a market-based iteration of reform. It’s going to have to be achieved piecemeal.”