The House of Representatives is scheduled to vote on The American Health Care Act ― the Republican’s Obamacare repeal and replace bill ― tomorrow. Facing stringent opposition by both far-right and moderate Republicans, GOP leadership unveiled a series of last-minute amendments late Monday night in a final attempt to corral enough support to pass the bill through the House this week.
Amendments to appeal conservatives include giving the states the option to institute work requirements in Medicaid and block grant the program, whereas for centrist Republicans, House leaderships promises larger tax credits to help elderly Americans afford health insurance, whose premiums are poised to jump under the Republican plan.
The ACA currently restricts how much insurers can charge their eldest enrollees in the individual market, known as the age band. Under current law, insurers can only charge their oldest enrollee three times as much as their youngest. The Republican bill modifies that provision and allows insurers to charge their eldest enrollees up to five times as much as their youngest. This makes premiums cheaper for younger, healthier people and more expensive for older, sicker people. As a result, as premiums rise and become unaffordable for older enrollees, they’ll drop out of the market. This change threatens to leave those who are most likely to get sick and need health care most urgently without affordable coverage.
The Congressional Budget Office (CBO) estimates that under the Affordable Care Act, a 64-year old making an income of $26,500 per year would pay approximately $1,700 in premiums for health insurance, about 6% of their income. Under the Republican plan, they estimate that that number will skyrocket to $14,600, or over 55% of their income.
Influenced by pushback from moderate Republicans alarmed by the CBO estimates, the amendment allows Americans to deduct medical expenses that exceed 5.8% of their income from their taxes versus 10% under current law. Despite the fact that low-income Americans between 50-64 currently don’t pay much in federal income taxes, this provision really serves as a placeholder for approximately $85 billion for tax credits to help elderly Americans purchase health insurance. The kicker, however, is that this amendment to the House bill wouldn’t set up these tax credits, it simply earmarks the money and promises both hesitant Representatives and voters that the Senate will somehow figure out how to distribute it adequately later. Funding is being increased as a tax deduction to get the bill passed in a more conservative House, and the details of replacing it as a tax credit are left to the more moderate Senate. In other words, House Republicans literally have to pass their own health care bill to find out what’s in it.
This strategy is neither unique nor new. In 1981, the Reagan White House presented Congress with a budget plan that claimed to showcase its success of significantly cutting federal spending by hiding vague, unspecified cuts in the small print of various budget documents. This strategy, which came to be known as the “magic asterisk,” represented to-be-determined spending cuts that Reagan’s administration promised to figure out sometime later. In effect, the White House couldn’t figure out how to make its numbers add up and used these asterisks as placeholders under the pretense that they would sort out the details later.
Paul Ryan and Tom Price, both former Chairmen of the House Budget Committee, have each pulled this trick before. Ryan, whose reputation as a budget hawk and policy wonk precedes him, regularly used magic asterisks in his House GOP budget blueprints. His budget plans each year regularly advocated for tax cuts, but provided no explanation for how the government would cut tax expenditures to pay for them, instead leaving a blank spot where those spending reductions were to be specified. Ryan merely waved his hand, said “let there be tax cuts,” and there supposedly were. Similarly, Price, the current Health and Human Services Secretary, pushed a House GOP budget blueprint in 2015 that called for a massive $1.1 trillion in federal spending cuts over ten years without specifying where those cuts would come from, and simply dodged the question when asked point-blank by reporters.
Simply put, GOP leadership knows that the tax credits under the American Health Care Act are insufficient, but they haven’t figured out how to fix the problem and don’t seem willing to take the time to do so. Ultimately, the magic asterisk is a sign that the majority of Congressional Republicans don’t seem to care about health care policy or its impact on citizens; they’re so intent on getting a “win” by pushing this bill through by Thursday and moving on to tax reform that they’ve given up the true question of policymaking, not whether or not a bill will pass, but rather whether or not it will actually do what its writers claim it will.
Despite the rush, it’s still uncertain if these amendments will pull together the 218 votes needed for this bill to pass through the House, especially from members of the House Freedom Caucus, which has been thoroughly critical of the bill and pessimistic about amendment negotiations. The White House and GOP leadership, however, are feeling confident. Elderly Americans, many of whose lives are hanging on the threads of health care reform, likely aren’t.