Veni, vidi, addixi: RIP, Ryancare

Last updated on: March 26, 2017 at 8:03 am by Jane the Actuary

Veni, vidi, addixi: RIP, Ryancare 2017-03-26T08:03:22-06:00 Jane the Actuary

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So it’s official: the GOP has had so little support for the “American Health Care Act” that it pulled the plug and is now saying, “well, we tried — on to tax reform!”

In other words, bitching and moaning about Obamacare has proven easier than fixing it — not because the fixes were too difficult, but because the Republican leadership just didn’t have the political skills needed to corral a fractious party.

To be sure, the Ryancare plan had a lot of flaws, chief among them being that it preserved the pre-existing condition restriction restriction, while at the same time eliminating the mandate that was meant to force enough people into the pool to control the death spiral this provision would otherwise produce, as well as the substantial decrease in subsidy level for those at an income level low enough that purchasing health insurance on the open market would simply be too great a financial hardship, and with respect to whom the new consensus is that it simply isn’t adequate to assume that emergency treatment mandates, payment plans, hospital financial assistance programs, direct charity care, and the write-off of bad debt will be sufficient.

But these were not the complaints of the Freedom Caucus. To the best of my understanding (and the Washington Post provides some of the background and context) they really, truly, wanted a full repeal, or as close as they could get, and, specifically wanted the elimination of the “essential health benefits” provision of the ACA. (According to the Washington Examiner, they had even more wide-ranging demands, including the elimination of the ACA’s bans on lifetime limits, the preventive care requirements, the “single risk pool” requirement, and so on. But I think the EHB elimination was their non-negotiable.)

Now, the “essential health benefits” are very broad categories of benefits: outpatient care, ER visits, in-hospital care, maternity care, mental health/chemical dependency, prescription drugs, rehab and related therapies, lab tests, preventives services, and pediatric services. (This list is everywhere, but see, for instance, NBC News.) The exact mechanics of how this provision of the law works are not as simple as saying that all health plans must cover all services listed in these categories, and must do so at identical coverage levels; there’s some degree to which the specific services are then set based on a “benchmark plan” at the state level, and, to be honest, I’m not entirely certain how that works.

I’m also not certain exactly what was underlying the Freedom Caucus’s demand here: did they want to enable insurers to offer plans without maternity, or without mental health coverage? Or was their demand more symbolic, that without some element of removing the ACA’s extensive regulatory component, Trump and the Republican leadership weren’t fulfilling their “repeal” pledge?

But, again, if I understand correctly, what it boiled down to is that the Freedom Caucus wasn’t willing to “play by the rules.” As laid out by the GOP leadership, only bills that have to do with “budgetary” items can be passed by a pure majority vote in the Senate; anything else and the bill is filibuster-able. But the Freedom Caucus rejected this. It’s not clear to me from what I’ve read, whether they thought they could push the bill through with 51 votes, because of some arcane loopholes that would allow them to get this through, or whether they could shove this through by “brute force”, or whether they simply wanted to be able to vote on “their” bill, even if only symbolically, and with the understanding that those provisions wouldn’t survive.

Honestly, I’ve read the description multiple times. Maybe I’m too tired at the moment. But I’m just not clear on which it is — though, ultimately it doesn’t matter, except perhaps in determining whether they’re fools (for valuing the objective of a purely symbolic vote) or ***es for trying to push the leadership to do something that really seems to have been stretching the Senate rules to such a degree as to be unethical.

The bottom line, though, is that Trump couldn’t persuade these recalcitrant congressmen to accept their half-loaf, and probably didn’t try very hard, and then went on-camera to say, “hey, we tried; now we’re finished with that and going to move on to other things, and will return to Obamacare when it implodes.” But that isn’t a path forward.

Yes, maybe another round of premium increases might get the public riled up, but the Democrats are getting increasingly set on Single Payer, and are not especially sympathetic toward those with rising premiums, who are generally those who don’t qualify for subsidies: after all, what they are ultimately complaining about is the new obligation imposed on them to subsidize their ill fellow citizens, which they should accept without complaint. And the horror stories of doubled premiums, of deductible of $10K per year, and equally-high premiums, we’re told, are the rare exception to the rule. So I simply can’t see the Democrats running to the Republicans for help in a way that produces a useful compromise.

So does this mean that Trump and Ryan turn out to be failures at what was supposed to be Trump’s signature skill, negotiation? Or were the Freedom Caucus folks simply so intractable in their demands that no degree of negotiation skill would have gotten them to budge? Of course, either way, the final outcome is both a disappointment, and admittedly also a relief.

But the whole episode over the last several weeks has even been all the more frustrating because, well, it’s been a matter of watching the home team fail, rather than the guys you hate anyway. I liked Ryan and his plans to bring new ideas to government. Sigh. . .

Image: https://commons.wikimedia.org/wiki/File%3ADoctor_examines_patient_(1).jpg; By Unknown photographer [Public domain], via Wikimedia Commons

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