Tom Miller, a resident fellow at the American Enterprise Institute (AEI) specializing in health insurance regulation, discussed the Senate’s Obamacare reform bill with SiriusXM host Alex Marlow on Monday’s Breitbart News Daily.
Miller described the Senate bill in its current form as “a damaged deconstruction site, and it’s not very pretty.”
“The reason why things are not clear-cut is because they’re operating under the particular rules of the Senate, which means they can do some things and not other things,” he explained. “They’re hunting around for votes, and that’s never a pretty sight. So we’re not getting any type of simple coherent approach for getting from here to there, from the Affordable Care Act to something else.”
“If you want to simplify it, what looks to be coming out of the Senate version of this is they’re going stronger on trying to roll back the Medicaid expansion through a number of devices, and they may give some ground on that in order to get some other votes,” he continued. “They’re getting rid of all the taxes under the Affordable Care Act. There are some delays in the particular dates for when some of them end.”
“And they’ve gotten a lot lighter on changing the individual insurance markets, so it ends up being similar to the Affordable Care Act, with some adjustments in terms of how people are subsidized – a little different method, but they haven’t blown up the entire enterprise,” he added. “These plans would tend to be less comprehensive and subsidized a little bit differently than they currently are but still a little bit sensitive to income.”
“That’s the short version of it. Whether that gets 50 votes in the Senate is still a good bit of a guess,” Miller concluded.
Marlow asked why the Senate plan keeps so much of Obamacare intact instead of repealing it and starting from scratch, as Republican politicians so often promised they would do.
“Well, they don’t have all of the tools you could possibly have on the regulatory side because it’s done through budget reconciliation, so that ties one-and-a half of your hands behind the back,” Miller replied.
“Secondly, there’s much greater sensitivity to the reactions of people who would be saying, ‘I’m losing what I have’ or on the health industry side,” he added. “This is standard politics. All of the folks currently getting fed and then paid off don’t want to let go of that.”
“And then on top of that, you’ve got to deal with how this looks in terms of what the Congressional Budget Office will say: Everybody is losing their insurance, and it doesn’t save enough money. All of that puts you in a very difficult box. I’m not trying to say this is a virtuous enterprise, but there are explanations for why they look a little contradictory and confused because it’s been a long time since this law was passed in 2010. The anxieties about disruption and instability, blah blah blah, tend to have members in elective office pulling their punches to a great degree,” he said.
Invited to list the good and bad features of the Senate plan, Miller said the list of good features was shorter.
“The good thing is, after talking and talking and talking, even before March of 2010, they’re actually voting on something – which is partly a little bit more accountability than just giving campaign speeches and promises,” he said. “Although we’ll have some more posturing, ultimately people are on the record in one form or another, whether they like it or not.”
“The fact that the individual mandate – which is pretty weak and not really having big consequences in enforcement – would finally be gone, that’s a good thing,” he continued. “The employer mandate, which is even less consequential, that’s a good thing that that would be gone. They basically make the penalty zero under it.”
“Hypothetically, states might be able to do some more things they couldn’t do before, although we can exaggerate the degree to which that’s going to happen across the country,” he said.
“The subsidy structure is still pretty fraught in the individual market under this bill, but it tends to be a little bit better than the Affordable Care Act, and that’s not saying much, although this only goes to kind of a slice of the market. If you weren’t getting subsidized under the Affordable Care Act under your income, that’s not going to change under this one, unlike the way the House bill operated on it,” he said.
“Medicaid has been kind of blowing up out of control,” Miller observed. “This is going to slowly close that down through a combination of subsidizing the states to a lesser degree, capping that and rolling it back, and also eventually having more of an inflation indexing for future growth, mostly per-capita allotments for different parts of the program.”
“Beyond that, the regulatory stuff is still a mess, and we’re still caught in the swamp we’ve been in before. There’s nothing you can call clear-cut free market principles behind this. It’s just managing within the box and making it a little less onerous,” he said.
Miller broke Republican opponents of the Senate bill into “two competing blocs.” One of those groups is the conservative senators who “want to see more aggressive measures to upend the Affordable Care Act structure, more so in the individual market.”
“On the margins, maybe they’d like a little bit more taken out of Medicaid, but that’s not going to work because there’s another group of Republican senators who are trying to hold on to as much as they currently have and would like to push in the opposite direction,” he said.
“There are a lot of things the other Republicans would like that would tend to open up the individual market a little bit more broadly, although there is a provision for waivers under an old section of the bill that would be changed, where states could get waivers to do a little bit more on the regulatory front – mostly reducing essential health benefit requirements,” Miller noted.
“It’s hard to go much further and stay within the bounds of budget reconciliation, despite what they might argue for. So that’s going to mean problems with the Senate parliamentarian, to be able to do something more broadly,” he said.
“They may be able to get a handful of marginal concessions, but there’s not much more to give on that front. You’re talking mostly about Sens. Lee, Cruz, Johnson, Rand Paul,” he said. “Rand’s going to vote against it anyway; that’s pretty clear-cut.”
Marlow said it seemed equally clear that Sen. Mike Lee, who has dismissed the Senate bill in its current form as a “caricature of a Republican health care bill,” would not vote for it either.
“Where does that leave us?” Marlow asked.
“Where it leaves us is, either they have a vote later this week and come short of 50, or they pull it back and try to pretend they can do more in July, but it’s probably not going to get much better,” Miller replied.
“There’s deal-cutting, which may bring on some moderate Senate Republicans; that remains to be seen. It depends how much money they have to move around after the CBO score comes out, probably later today. It’s a very difficult legislative exercise to assemble 50 Republicans with only two defectors at this point. Miracles happen, but it’s uphill,” he said.
“You have to look at where the public support is,” Miller advised, in response to a caller’s question about scrapping Obamacare completely and starting over with a more state-oriented system. “A number of people look at this in a principled manner and would like to say, ‘Let’s have a simpler, cleaner approach to this.’ There aren’t enough votes, and there’s not enough support to do that. That’s the fact of the matter.”
“We had a better chance years ago, but a lot of water has gone over the bridge,” he said, either accidentally or deliberately changing the old saying about “water under the bridge.”
“People have to expand their group of supporters of those type of principles. They’re not there right now, and their representatives in Washington react to that – not that they’re virtuous on their own,” he pointed out.
“So the problem is, we really want to have individuals running the show, not even states – which is another extension beyond that, but obviously, it’s better to have this spread among 50 states than one central government. It’s just not there. If you actually look at what people want, and they’re confused on this, they’d like to hold on to what they have and have someone else pay the bills. We’re not particularly virtuous as a voting public on that front when it comes to health care,” Miller said.
Miller acknowledged the premium increases under Obamacare regulations, especially in the small-group market, but said the people who “ended up on the short end of the stick” tend to be obscured by the political focus on people who have something to lose if Obamacare is repealed.
“Particularly, if they were very low income, they get much, much bigger subsidies, who would seem to be the winners compared to where they were before,” he said of the latter group. “No one’s going to come out in exactly the same place again when you make those many changes.” “Certainly, we’ve ignored the people who were hurt by this process, and a different type of environment and regulations, more open, would be of benefit to them,” he said. “And you’ll get the counter-reaction that the people who now currently have subsidized coverage would get less.”
“Certainly, we’ve ignored the people who were hurt by this process, and a different type of environment and regulations, more open, would be of benefit to them,” he said. “And you’ll get the counter-reaction that the people who now currently have subsidized coverage would get less.”
“That’s the nature of when you put the government in charge of things. There’s no clean slate of winners and losers. Some people come out ahead, and some fall behind. We don’t have a neutral environment on some type of broader set of principles,” said Miller.
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