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ACA Deathwatch – A Zero-Sum game

The ACA repeal movement may have gained a bit of momentum this week…The quick take – odds are this momentum will peter out as changes wanted by some Republicans are anathema to others.

My take is the hands on the Deathwatch Clock just moved back – not forward.

Here’s what’s going on.

The White House continues to push for a vote in the House by the end of this week, apparently to give President Trump a “win” in his first 100 days.

Hard-right Freedom Caucus Republicans have apparently agreed to a rough outline of a repeal plan. (details below)

Somewhat-more-moderate Republicans have publicly weighed in on the outline, and there’s a good bit of concern over coverage for pre-ex conditions and other provisions.

While the challenge faced by the Republicans is pretty straightforward, the solution is anything but. Put simply, changes that get support from the hard-right reduce support from more-moderate Republicans; It’s a zero sum game.

And that’s before it gets to the Senate, where it will die because Senate Republicans are loathe to pass anything remotely resembling AHCA.

Details on the latest legislation

Healthcare is brutally complicated, a reality that’s becoming increasingly apparent to GOP negotiators. To get to some sort of agreement between hard-rights and more-moderates, the latest repeal legislation includes:

  • waivers that allow states to set insurance premiums for older people 5 times higher than younger folks
  • ability for states to let insurance companies eliminate or limit coverage for different types of medical care – drugs, therapy, behavioral health, nursing home care, etc.
  • ability for insurance companies to “medically underwrite” individual and small group insurance again – in English, let insurers decide whether to cover you, and how much to charge, based on your medical history and risk factors.  To do this, states will have to provide high-risk insurance pools to help offset losses (this is a really complicated solution that hasn’t ever worked)

I won’t bore you with the nitty-gritty details, you can read them here.

What’s becoming increasingly apparent to Republicans in DC is they have a Hobson’s choice.

There is no way they can deliver on their campaign promise to repeal ACA and replace it with anything that won’t piss off a lot of their supporters.

But if they don’t repeal ACA, that will really piss off a lot of their supporters.

Add a President who doesn’t care what legislation does or doesn’t do, but cares a lot about “winning”, and we now understand why they are in the mess they are.

What does this mean for you?

The GOP has yet to transition from opposition to governing party.

4 thoughts on “ACA Deathwatch – A Zero-Sum game”

  1. I think you have summed it up perfectly and the pot will really get stirred when they decide if they are going to fund the current program, which I believe is a decision that must be made soon.

  2. I thought that it was particularly telling when Congress was going to exempt their health care from the proposed replacement. It obviously is not good enough for them or their families.

  3. Thanks, Joe. This is very helpful information as always — a special thanks for staying somewhat down the political middle as we have plenty dividing this country…

    For me it is very interesting to watch the clash on allowing companies to ‘medically underwrite’ risk and those of you coming unglued that HIGHER RISK = HIGHER PRICE. In my tiny brain, since older people pull out ~5 times more of the costs from the insurance cost cookie jar, they should put in 5 times more… This sounds like common sense to me and applies to every other area of insurance (getting DUI’s = higher auto premium; burn down your house multiple times and your home premium just might be higher; companies who have unsafe workplaces and/or employee fatalities pay higher premiums, on and on I could go…..).

    High risk pools have worked in many other areas of insurance — don’t we already have a form of pooling today called Medicare where we pulled out the ‘highest risk” (older people) into a separate “pool” outside the marketplace, the government recovers costs from it’s customers (that’s you and me) to keep the heathcare marketplace stable and eliminate the significant premium swings?

    These are very different times and interesting to watch as Trump is asking politicians to put citizens ahead of politics and do what is right for citizens and not for their votes/elections…. you are correct that they are not going to please everyone but they never have…. while we look on like kids at the zoo watching the gorillas play (and hurling some ‘stuff’ at us).

    Also, I am sad I have to admit that (so far) you were absolutely correct on the refusal of Democrats to enter into the dialogue and work together on this massive issue. Really sad where our country is headed.

    1. John – thanks for the note. Three observations.

      1. Medicare was put into place because seniors could not get insurance anywhere at any price. The “free market” would not insure them, so government had to step in. For those lauding the market as the solution to all ills, I’d suggest revisiting Medicare.

      Which leads to 2.

      2. Insurers will NOT cover individuals’ pre-existing conditions voluntarily – doing so would be foolhardy unless the insurer gets a huge premium. Prior to ACA, insurers in some states could charge up to 9x for coverage of those with pre-ex. And that was in those states where insurers were forced to do so; in others insurers just refused coverage. This happened to me, and millions of others.

      3. High risk pools have NEVER worked in health insurance for reasons enumerated here. The proposed funding is grossly insufficient and it is impossible to identify “high risk” individuals up front.

      As to Democrats’ position, after the scorched-earth politics of McConnell et al, no sane Democrat would want to work with a group that excoriated, insulted, demeaned, and obstructed Dems’ efforts over 8 years. Dems worked closely with Republicans in constructing ACA years ago, and despite all those efforts (discussed elsewhere here) no Republicans signed on.

      Asking for bipartisanship today is a rather heavy lift given recent history.

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Joe Paduda is the principal of Health Strategy Associates




A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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