And so the heaviest legislative lift for President Trump and Republicans in Congress begins, with the unveiling on Monday of health care reform that would terminate the Affordable Care Act and replace it with legislation centered on three basic premises:
Devolving control from the federal government to the states
Tax credits for those who have suffered the most under ACA: small businesses and people not covered by employer health care plans.
Expansion of Health Savings Accounts (HSA's) to allow individuals more control over their own healthcare
The proposed bill will be processed by two House committees before the full House takes it up. The House Ways and Means Committee begins markup of the legislation on Wednesday. The full text of the bill is available here.
Importantly, the bill is designed for passage by the same budget reconciliation process employed by Democrats in pushing through the ACA. This means just 51 votes would be needed in the Senate instead of the 60 required in the normal legislative process. However, this process also means two elements favored by many in the GOP - the ability to buy insurance across state lines and tort reform capping malpractice awards - were not included in the bill because they are not part of the budgetary process.
Gone are most all of the government controls - individual and employer mandates, taxes and subsidies - which made ACA deeply unpopular among the American people. The landmark legislation and signature achievement of the Obama presidency passed by the narrowest of margins, with zero Republican support. The central promises upon which Obamacare was sold by the former president - that you could keep your doctor, keep your existing health coverage and save money - went unfulfilled. Both Trump and GOP candidates across the land made the repeal and replacement of the ACA a central issue in the 2016 election campaign.
Vestiges of Obamacare preserved in the new bill are coverage for pre-existing conditions, the ability for children to remain on their parents' plans until age 26, and no lifetime caps on coverage. Low-income and high-risk individuals who received coverage under ACA would be accounted for by a new "Patient and State Stability Fund." Those currently enrolled in Obamacare would be allowed to remain in their current plans through 2020, the same year the Medicaid expansion which has covered most low-income enrollees would be terminated.
If this bill is passed, the Democrats will effectively hand ownership of the healthcare issue over to Republicans, who will live with both the rewards and consequences of the second dramatic reform of one-sixth of the American economy in the last seven years. It is difficult to imagine it could be more unpopular than Obamacare.
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