Charles Grassley on Repeal-and-Replace Bill: What a Piece of Shit

That's Finding Four in the document.

Couple of points: We can call this the "Ryan Repeal" but the fact is that Trump is pushing to keep a lot of this Big Daddy Socialism crap. So's Susan Collins, actually (she said that the bill had to appease "Senate moderates" as well as conservative), but Trump's central role in mainstreaming the socialization of medicine shouldn't be overlooked here.

Although Grassley's staff find that many parts of the repeal track the language (or nearly do) the 2015/2016 Reconciliation Bill to repeal Obamacare, they find the bill as presented insufficient:

This plan fails to repeal most of the costly mandates and insurance regulations driving up premiums and deductibles

This plan replaces Obamacare’s subsidy scheme with a new costly federal entitlement in the form of a refundable tax credit

This plan leaves significant portions of the flawed and costly Medicaid expansion intact by delaying the freeze on Medicaid enrollment, maintaining the expansion of the program to the able-bodied, and providing a pathway for non-expansion states to accept enhanced federal dollars.

There is one part I disagree with him on: The claim that this doesn't get rid of the mandate.

It does.

From the analysis:

Continuous Coverage: Requires insurers, beginning after the 2018 open enrollment period (i.e., open enrollment for 2019, or special enrollment periods during the 2018 plan year), to increase premiums for individuals without continuous health insurance coverage. The premium could increase by 30 percent for individuals who have a coverage gap of more than 63 days during the previous 12 months. Insurers could maintain the 30 percent premium increase for a 12 month period. Requires individuals to show proof of continuous coverage, and requires insurers to provide said proof in the form of certificates. Some conservatives may be concerned that this provision maintains the federal intrusion over insurance markets exacerbated by Obamacare, rather than devolving insurance regulation back to the states.

The only part of this that I think is worthy of agreeing with is the bit about "federal intrusion over insurance markets" not being fully repealed and all powers returned to the states.

But I get the political appeal of keeping a kind of no-pre-existing-conditions-ban clause. Trump ran on it, for one thing. For another thing, it seems to be one of the three parts of Obamacare that's actually popular.

Putting aside the federalism question for one moment -- and you can come back to that and deem that sufficient to doom this section if you like, but putting it aside just for this moment -- this is not a "mandate."

This says that insurance companies can raise your rates if you choose not to maintain coverage.

Think of the alternative (and this is the whole reason the mandate existed in the first place):

If you are free to game the system, and not pay for insurance until you learn you need a quadruple bypass, you will wind up paying the same rate healthy people do for the three of four months you need coverage (for the surgery and follow-ups). Then you can drop it.

The cost to you for such an expensive bit of medical work? A couple of thousand dollars. The actual cost, passed on to all other taxpayers? $60,000.

The whole point of insurance is that you pay when you don't need it to use it when you do. People who don't pay when they don't need it, and only pay when they do need it, are gaming the system and throwing their costs on to everyone else.

So you can have some kind of penalty for not maintaining insurance or an end to the pre-existing conditions bar, but you cannot have both at the same time.

This is not a mandate. You're not obligated to keep insurance. You're just being told that insurers can hit you with higher costs if you don't. (And in fact, given that someone who doesn't have insurance but then signs up for it after a major car accident requiring a couple of months of hospitalization, treatment, and physical therapy will rack up huge bills, I'm not even sure the 30% penalty is enough to make sure other insurees aren't being forced to pick up his costs. Maybe 50% or 60% is needed.)

So yeah, I see the objection to continuing federal interference, but frankly, even the federal interference that you should be allowed to sell insurance across state lines is federal interference, because most states would say you can't.

But the 30% penalty for 12 months for not maintaining insurance is not a mandate -- it's the cost you have to pay for attempting to shift costs to other people, and even then, it probably comes nowhere near covering the costs a quickie-sign up will cost the insurance pool.

Rather than being a mandate -- a legal obligation -- it's probably not even tough enough stick to be an effective deterrent.

True free-marketers/free-choicers would probably say: "If people choose to go without insurance, it's on them, not any other citizen, to pick up their costs when a major expense comes up. Your pre-existing condition is not my post-facto problem."

True enough. But as a political matter, it seems to me this ship has sailed, and no one even tried to catch it when it sailed ten years ago.

posted by Ace at 01:15 PM

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