Dem
47
GOP
53
One of the things the Democrats got out of the government shutdown (maybe the only concrete thing) is a promise that the Senate would vote on extending the ACA subsidies. Unlike the previous Republican Senate Majority Leader, Sen. John Thune (R-SD) is a man of honor. Today's the day and the vote will be held. But Republicans were embarrassed at just voting against the subsidies with nothing to offer themselves. So, Sens. Mike Crapo (R-ID) and Bill Cassidy (R-LA) cobbled together an alternative bill. Neither the Democratic bill nor the Republican one is going to get 60 votes. Then it will get tricky.
Crapo and Cassidy chair the Finance and HELP committees, respectively. Crapo was a lawyer in private practice before being elected to the Idaho state Senate. Cassidy worked as a physician. Their plan would allow eligible people who buy a bronze plan on an ACA exchange to get $1,000 (under 50s) to $1,500 (over 50s) deposited into their Health Savings Account to help pay for it. Bronze plans typically have a deductible of $7,500 for one person and $15,000 for a family plan each year, so you have to be quite sick to get any payout. The deposits would be for 2026 and 2027 only. Donald Trump likes the idea of sending government money to people directly like this, since it connects him to the money.
The consequence of this plan is that people who qualify have to buy what is essentially junk insurance, even though the government check can be used to pay part of the premium. If they get sick, they will be whacked with about $7,500 in bills and often some copayment if the bill exceeds that. Sabrina Corlette, a Georgetown professor who is an expert on health care policy, said the bill amounts to "offering people a 1-foot rope to get out of a 10-foot hole."
If and when the bills put forward by each caucus fail, ACA premiums will spike in January. Regular plans, offered through employers, are also expected to get more expensive in January. Almost half of all adults are worried that they won't have money for health costs in the coming year. This is the "affordability" issue discussed above. For example, Sen. Thom Tillis (R-NC) said he heard from a constituent who is paying $800/mo for a couple and three children. The insurance company just told the constituent that absent the subsidies, his premium would rise to $1,600/mo.
The danger for Republicans is that if both bills fail and the subsidies indeed vanish, Donald Trump will get the blame, no matter how much he fulminates. He promised to lower prices during his campaign and Democrats will hammer him on grocery prices, housing prices, and health care prices next year. In the unlikely event that Crapo-Cassidy passes, people will still blame Trump once they find out how little the bill actually does and how few people are eligible for it.
There are a couple of other Republican plans being kicked around, but none of them continue the ACA subsidies. None of the others have a chance of passing, either.
Crapo-Cassidy was likely inspired by the RyanCare plan pushed by former House speaker Paul Ryan (R). In RyanCare, insurance companies could refuse to insure sick people. Since they would only have healthy people in their pool, they could lower premiums. This would be a win for something like 80% of the population, the same as for healthy people buying junk insurance and getting to keep the $1,000 or $1,500, and have a low premium. In RyanCare, the estimated 20% of the population who are uninsurable would go into a government pool where health care costs would be paid by an annual appropriation from Congress. That would cap the government's cost. It also means that if the appropriation ran out in August, no bills submitted in Sept.-Dec. would be paid. Members would be instructed to get sick early in the year, before the money ran out. In both cases, RyanCare and Crapo-Cassidy, young healthy people would be winners and old sick people would be losers. Ryan figured that if 80% of the voters pulled the lever for the GOP and 20% were hopping mad and voted Democratic, he could live with that.
If both bills fail today, then what? One possibility is that Republicans do nothing and there is a lot of stove touching. Republicans really don't want that, but they also don't want to extend the ACA subsidies. What will they do? Play "Kick the can past the midterms?" Wouldn't be the first time. The one thing that is certain is that voters who are wildly unhappy about their health care (and other) costs do not generally vote for "more of the same, please!" And everyone knows which party has the trifecta right now. (V)