Is McConnell Playing The Long Game On Health Care?

Mitch McConnell, no matter how much you dislike him, is a dangerous man who is a master at political maneuvering. He has been remarkably silent throughout the whole AHCA debacle in the House and, maybe it's just my paranoia, but I can't help but feel that he has some devious plan to accomplish the major Republican goal of massive tax cuts for businesses and the top 1% while rolling back as many restrictions on corporate power as he possibly can. And, as we know, repealing the taxes on the rich that support the ACA is part and parcel of that process. All of which makes me think he just might be playing the long game on health care.

Anything the Senate wants to get done on health care will have to be done under the budget reconciliation process which only requires the 50 votes plus Mike Pence to pass. Anything outside of that process will require 60 votes and be filibustered by Democrats. There are three enormous problems with the bill that the House passed that make it highly unlikely the Senate parliamentarian will allow them to be included in budget reconciliation. The first is the ability for states to opt out of the essential benefits that the ACA currently requires. This covers things like pre-existing conditions and lifetime caps. The second is the 30% surcharge for not maintaining continuous coverage. And the third is allowing insurers to increase the cost ratio of older to younger insured from 3:1 to 5:1. Of course, the first and the third of those hurdles are what made the bill "work' in the House and allowed it to get passed at all.

Knowing this, it is not surprising that McConnell has already declared that the Senate will write its own bill from scratch. That bill will probably substantially decrease the amount of Medicare cuts that the House bill envisions. Other than that, it is hard to know what the Senate bill would look like, other than reducing those ACA taxes. But with the essential ACA benefits in place, doing so would run into the same problems that the House chose to ignore. Millions of Republican voters would no longer receive subsidies and the insurers themselves would also suffer. And in addition to taking care of the Medicaid issue for many more moderate GOP Senators, McConnell has to worry about the three bomb-throwers in his caucus, Ted Cruz, Mike Lee, and Rand Paul, of which the former two are adamantly determined to repeal Obamacare in its entirety.

But a worrying sign, to me at least, is that after having been silent about the House bill for the last two months, America's Health Insurance Plans (AHIP), the lobbying group that represents health insurers, absolutely the group most effected by any changes to the ACA, finally issued a statement that said, "Immediate challenges exist in the individual market today, and the bill includes key provisions to stabilize the market in 2018 and 2019. We need certainty now about funding for cost-sharing reductions that lower copayments for patients so they can better afford to get care from their doctor. The tax credit should be enhanced to reduce premiums and better meet the needs of people with low and modest incomes, are older, or live in areas with high health care costs. We want to work with the Senate to ensure the continued strength of the Medicaid program, which delivers real value to more than 70 million Americans.  States need adequate resources to administer an efficient, effective program that helps beneficiaries improve their health. If changes are made to criteria for who is covered by Medicaid, we need to give people more time to adjust – and more time for the individual market to stabilize." Pretty much everything in that statement runs counter to what's in the AHCA, but the fact that AHIP has only now broken its silence may indicate to someone as suspicious as I am that they have already worked out some sort of deal with McConnell already. What that may include, I have no idea.

Even if McConnell does manage to push through a bill under budget reconciliation, it would still have to go through the bill reconciliation process to "merge" it with the House version and then be voted on again by the House. Considering that the very items that finally got the Freedom Caucus to vote for the House bill will almost be definition not be included in the Senate bill, it is hard to see that it could pass again. And because of the limitations in the Senate, it is almost guaranteed that millions of Americans would still lose coverage under whatever bill came out of reconciliation. It is hard to see that reconciled bill getting through both the House and the Senate.

That leaves us with the scenario that the Senate either does nothing on health care at this point or crafts a bill that will either fail again in the House or be blocked by the Senate. And that process will take months. But that would leave the insurers who have to decide about participating in the ACA exchanges in 2018 to deal with uncertainty long past the decision date and it would no wonder that many of them would decide to drop out. Right now there are around 1,000 counties in the country that have only one insurer. There are a number of counties in Tennessee that have already lost their last insurer and a few days ago Medica announced its intention to pull out of Iowa, leaving most of that state without an insurer.

With the chaos that the Republicans have created around health insurance and the resulting decision for insurers to withdraw from certain less profitable markets, along with Trump's continued threat to withhold the insurer subsidies, it is possible that we will see significant parts of the country experience an ACA implosion in 2018. And Republicans will run hard in 2018 on blaming Democrats and the ACA for the collapse of the insurance market, just as they predicted. It could be a powerful argument, especially to those who live within the right wing echo chamber, and Democrats need to be prepared to fight it.

There are ten Democratic Senators up for re-election in 2018 who represent red states and the GOP will have a great campaign issue if those states have an ACA implosion to pound away at the Democrats. If Republicans hold their own and pick up eight of those seats, they will have a filibuster-proof majority in the Senate. Assuming that the extreme gerrymandering will allow the GOP to squeak by with a small majority in the House, then McConnell and the Republicans will have unfettered power and be able to do virtually anything they want with health care, taxes, the environment, the whole ball of wax. It's a big gamble but, if he pulls it off, it would frankly be Mitch McConnell's wet dream.