Health care: vote delayed, but calls to address costs keep growing

Senate Republicans have been forced into postponing major health care legislation in the United States Senate, and the backdrop is partly the difficult economics of health care: Costs for average Americans are high and rising, and the Senate legislation so far doesn’t appear to offer significant relief.

The challenge was highlighted on June 26, as the Congressional Budget Office came out with its score of the Better Care Reconciliation Act released by Senate Republicans. The CBO predicted that premiums would rise faster than under current law, through 2019, for people who aren’t insured through an employer or a government program.

And although the CBO’s nonpartisan scorekeepers forecast that premiums would then start coming in lower than under current law, they said the big reason for the drop would be the bill’s openness to less-generous health plans. So, it would be a cut in benefits more than in costs.

That’s tough news for a bill that was already under fire due to projections that its spending cuts would result in millions of people losing coverage. (The CBO report estimated that 22 million fewer Americans would have insurance as of 2026, largely due to cuts in Medicaid for the poor, disabled, and vulnerable.)

It helps explain why, as of June 27, Republicans in the Senate majority couldn’t muster the votes to even push their bill to the floor for debate, and have pushed the effort off until after the July 4 recess.

“Republicans have driven up a narrow, steep, hilly mountain road,” says Alan Sager, a professor of health law, policy, and management at Boston University. “It can be dangerous to back down. I think that's how they feel.”

Republicans are in a tricky spot. Moving forward with the bill as proposed could unsettle many working-class Republicans who might lose Medicaid or get less federal assistance for buying their own insurance.

Doing nothing isn’t an appealing option either, however. There’s the politics: Lawmakers would face criticism from their base if they fail to pass something that can be called an Obamacare repeal.

Beyond that, the nation’s health-policy challenges don’t go away. Health care in the US is the most expensive of more than a dozen high-income nations, a 2015 report found. Premiums and out-of-pocket expenses have been rising, and the state-based marketplaces under the Affordable Care Act (ACA), are seeing fewer insurers offering plans – at least partly due to the uncertainty created by Republicans’ own promises to unravel what Democrats passed in 2010.

Double-digit increases in premiums

Enrollment in ACA exchanges has also been lower than expected, according to health policy analysts. Fewer healthy customers have signed up relative to the number of enrollees who incur medical expenses.

This is now happening on Republicans’ watch, with the GOP in control of the White House and Congress as of January.

“The debate over the Affordable Care Act ... casts uncertainty over the market,” Dan Mendelson, president of the health consulting firm Avalere, said in a report released June 19.

In eight states where insurers have already formalized their proposed rates for 2018, premiums are headed upward by an average of 18 percent next year, according to analysis by Avalere.

In Virginia, for example, proposed premiums for the second-lowest-cost “silver” plan under the ACA would rise to $568 per month for a 50-year-old male nonsmoker, up from $464 for 2017.

The 2018 rises will follow an average silver-plan jump of 25 percent nationwide in 2017, according to government data. Income-based subsidies have helped soften the increases for many consumers.

And some 41 percent of counties in the eight states featured in the Avalere report have only one insurer offering plans for shoppers in the ACA marketplace, up from 8 percent in 2016.

Although repealing the ACA has long been popular as a talking point with Republican voters, voters of both parties care about access to affordable health care. And opinions of Obamacare, while mixed, have been growing more positive in recent polls.

A mid-June nationwide poll by the Kaiser Family Foundation found 51 percent of Americans have a favorable view of the ACA, versus 41 percent with unfavorable views. That’s a reversal from a year ago, when it was 42 percent with favorable views and 44 percent unfavorable.

Calls for bipartisan collaboration

According to the online news service Axios, Senate majority leader Mitch McConnell of Kentucky is telling his colleagues that they can’t simply stand back and watch the Obamacare exchanges dry up – and premiums soar further – amid political uncertainty. So it’s either pass their own bill or work with Democrats on legislation to shore up the marketplaces, compromise and all.

Sen. Susan Collins of Maine is among the Republicans who resisted the Senate bill as rolled out by Senator McConnell.

“Senate bill doesn’t fix ACA problems for rural Maine. Our hospitals are already struggling. 1 in 5 Mainers are on Medicaid,” she said via Twitter on June 26. Senator Collins, among the Senate’s few moderate Republicans, also nodded to the possibility of bipartisan cooperation. “I want to work w/ my GOP & Dem colleagues to fix the flaws in ACA. CBO analysis shows Senate bill won’t do it,” she tweeted.

Professor Sager in Boston says some cross-aisle collaboration in Congress might help.

“We've gotten into a lot of partisan fights about health care,” he says. “Maybe it's a plague on both their houses,” he adds, pointing to a flawed track record for both big-government approaches and the notion of trying to abdicate a government role in overseeing the market for medical care.

“We should use government action and market forces as tools,” he says. “We shouldn’t become idolaters toward either one.”