The Senate Republicans are pissing off their Teabagging cousins in the House GOP caucus because Senate Republicans face non-gerrymandered districts where the median voter is significantly to the left of the typical House Republican median voter. The GOP majority in the Senate depends on seats being held in New Hampshire, Pennsylvania, Ohio, Illinois, Wisconsin, North Carolina and Florida. All of those states voted for Obama in 2008 and almost all voted Obama in 2012. The incumbent GOP senators won in 2010 depressed and bleached white turnout mid-terms. The presidential year elctorate constrains the marginal majority members policy and political space.
Politico reports:
Members up for reelection in 2016, and some Republicans from purple states, are leery of launching a repeal without offering any sort of replacement. They’re reluctant to take away Obamacare subsidies for the lower-income and middle class without providing an alternative path to health coverage.
Other lawmakers are floating the idea of mixing repeal of part of Obamacare, such as the medical device tax, which is loathed by members of both parties, with non-health care items such as broader tax reform.
There is a deal space available if the Republican Senate was willing to first engage in policy making and trade-offs seriously, and then secondly be willing to jam the House GOP caucus.
A deal would give everyone something that they wanted. A potential deal could look like this.
Democrats get the family glitch fixed. The family glitch eliminates subsidy eligibility for families where at least one person is offered affordable, qualified coverage at work. Family coverage does not need to be offered or deemed affordable but subsidies are no longer eligible for the entire family. A few other technocratic clean-up amendments could be offered. The aspirational outcome of the deal for Democrats would be further coverage expansion by making Medicaid expansion even more enticing by either increasing the federal share of Legacy Medicaid for states that have expanded eligibility or increasing the length of time that the feds pay 100% for expansion programs. Shovel more money at the states as a lure for expansion as well as building a slightly better counter-cyclical insurance policy.
Republicans could get a couple of policy goodies. They could get a copper plan defined as QHP, and/or they could get the medical device tax repealed without a veto threat. They could get slightly more regressive tax treatment on HSAs. There are policy trade-offs that the veto position holding Democrats would not prefer in isolation but could swallow if they get other policy preferences.
There is a deal available here. But it probably won’t happen as the Republican Party does not have the ability to engage in health policy right now.
Punchy
No offense, but you’re seemingly blind when it comes to the politics of this. Once you start repealing anything ACA-related, then the RWNM goes full nitrous, demanding more changes (at the same time, claiming to have “fixed” Obamacare). You set the mindset that the program may be “flawed” in other ways and needs more tweaks, which the GOP will gladly supply (crippling the ACA).
Med tax, good or bad, needs to stay untouched for awhile until the ACA is fully entrenched as a successful, Democratically-inspired godsend for middle and lower class families. Once that’s cemented (years from now, IMO), then tweaks can be done without hurting its rep.
MattF
Senate Republicans are profoundly relieved that SOCUS didn’t force them to do something about health care. The notion that they would now raise health care issues voluntarily is a non-starter.
Bobby B.
“Come back here! I’ll bite your legs off!”
Richard Mayhew
@Punchy:
Disagree — the tax on medical devices is purely a financing mechanism. It is a means to an end, and since PPACA is coming in way under budget while still achieving its coverage goals, cutting some of the financing mechanism does not threaten the core elements of the law (mandate/mandate fee, guaranteed issue at community rating, low income subsidies).
There are elements of the law that need to be improved (family glitch is a big one) that Dems don’t have the votes to pass straight through Congress and won’t have the votes to do so until 2022 at the earliest. GIving up something to get something as a package deal is how normal haggling works.
Now giving up the medical device tax without getting anything in return is another issue entirely.
Another Holocene Human
There’s bipartisan support to do away with med device tax even though it’s pretty low percentage wise and makes a lot of rational policy sense.
I don’t agree, but it’s probably going away.
The government–maybe through Medicare?–really needs to fucking crack down on that sector, though. I mean, going beyond out and out fraud like those people who were selling hoverrounds with other people’s SSN’s.
There’s lots of fraud going on at the manufacturer’s level.
I guess we’ll need Dems (with spine) for that because Republicans don’t believe in eliminating fraud and waste. When they say that they mean transfer payments, entitlements. They mean you but hope you think they mean your neighbor.
Another Holocene Human
@Richard Mayhew:
From your lips to g-d’s ears. That family glitch SUCKS.
RSA
Hey, there’s subliminal poison in this post title. Also a goat.
raven
@RSA: eyes without a face
Betty Cracker
@RSA: I am shocked that it took seven comments for someone to point that out. Y’all are slipping.
Dennis
Exactly why is the medical device tax despised in both parties???? $$$$$ from lobbyists, of course. There is no great principle at work here.
Keith G
@Richard Mayhew: Even though this is your established norm, I just wanted to thank you for rocking it with so many thoughtfull, informative posts.
Another Holocene Human
@Dennis: Exactly. It’s not in OUR best interest to give it up.
raven
Omar Sharif RIP
http://www.theguardian.com/film/2015/jul/10/omar-sharif-dies-at-the-age-of-83
Mike J
@Dennis: There’s also jobs for constituents. Just because it’s good for companies in your district doesn’t mean it’s not also good for the citizens in your district.
I don’t expect Maria Cantwell to piss off the 80,000 who work at Boeing, and I don’t expect Al Franken to piss off the people in his state that work for medical device companies.
dedc79
@Betty Cracker: I figured we were supposed to read the post title with a three stooges accent.
pamelabrown53
@Another Holocene Human:
Actually, if we could get the trade to fix the family glitch, I think it would be well worth it: lobbyists or no lobbyists
.@Keith G:
Agree that Richard’s posts are both thoughtful and informative. In fact, I think he should collect his essays on ACA and the insurance industry into a book. I know I’d benefit having all the information at my fingertips.
Gin & Tonic
@raven: In addition to his acting chops, he was a world-class bridge player.
raven
The flag is down.
raven
@Gin & Tonic: Yuri!
John
I read this like 3 times and it doesn’t make sense. Is this the blog equivalent of a pocket dial?
Richard Mayhew
@RSA: fixed
Barry
@Richard Mayhew: “GIving up something to get something as a package deal is how normal haggling works.”
Haven’t you noticed that we are not in that world?
Lee
@John:
No this is a Richard Mayhew insurance/Obamacare post. When he first started posting here there was a steep learning curve for us readers. It takes awhile for these posts to be more than gobbly-gook.
If you have questions or don’t understand, please ask as Mr. Mayhew is very good at explaining even to us here at BJ.
SiubhanDuinne
I liked your first thread title better.
Robert M.
I agree completely, except that I see it as a bigger problem (understanding, of course, that your area of interest and expertise is health policy). The Republicans’ little collective-action problem on health policy is a subset of their bigger problem with virtually every aspect of policymaking and governance. They spent fifty years attempting to convince voters that government programs are inefficient and ineffective by definition, and that every problem can be solved with lower taxes, less regulation, or both.
And that has left them fundamentally unable to engage in any area of policy that uses regulation or spends money to solve a problem, which is… you know, basically every area of policy.
Richard Mayhew
@John: Let’s pretend we are in a world where both political parties have positive policy goals. One area of disagreement is health policy. Democrats want to exapnd coverage, Republicans want more consumer directed/high deductible health plans.
So a deal in that world would be to tweak a provision in the ACA that denies subsidized coverage to families where 1 person has employer coverage but no one else does to allow that 1 person to keep their employer coverage and the rest of the family to get subsidized coverage. The best case scenario would be to get that goal plus make Medicaid Expansion more attractive to the hold-out states to get Medicaid expansion coverage in more states.
Republicans would get a policy tweak in their favor as well. Currently 60% of expected medical cost is the minimal allowed coverage to avoid the mandate penalty. That is called “Bronze”. The tweak would be to allow plans that cover 50% of expected medical costs (“Copper plans”) to be considered minimal allowable coverage.
The other tweak would be to repeal a 2.9% sales/excise tax on medical devices as there is probably 60% of both chambers would vote for a repeal without replacing the revenue and 65% to 70% of both chambers would vote for a repeal with revenue replacement in principle. However Obama would probably veto a stand-alone medical device tax repeal (why give something up without getting something in return) and there probably is a blocking minority in at least one chamber to sustain his veto.
That make sense?
The entire point of this post is that such a deal is imaginable with a very different Republican Party.
Richard Mayhew
@Robert M.: Completely agree with your larger point — if the “problem” can not be solved by deregulation, upper income tax cuts, looting or bombing, the GOP has no interest or ability to do actually formulate policy.
Xantar
Insurance companies are starting to propose their premiums for next year on the exchanges, and predictably the media is freaking out because a few companies are asking for humongous 30% rate hikes (usually Blue Cross companies). And naturally Obamacare is at fault.
There are a couple of things to keep in mind when talking about this with someone:
1. Many of those rate hikes haven’t been approved by state regulators yet. It’s not uncommon for an insurance company to ask for 30% and only get 9% approved instead.
2. As Richard noted in a previous post, a lot of insurance companies offered policies under cost on the exchange in order to attract more members. They’re now jacking their rates up to a more sustainable amount and hoping not too many people jump ship.
3. Which by the way means that if this happens to you, you should go on the exchange and buy a different plan. This is how competition works.
4. Taken overall and in aggregate, the insurance rate hikes this year aren’t any worse than they were before Obamacare. Focusing only on the extreme 30% rate hikes ignores all the companies asking for much more modest increases or even decreases. Here in Maryland, two of the insurance companies on the exchange are asking to lower their premiums next year.
MomSense
@Lee:
That is a perfect description of this Mayhew journey we have been on at balloon-juice. Sometimes the posts still are gobbly-gook until we read them about 10 times and ask a ton of follow up questions. We are pretty spoiled here to have access to Mayhew.
boatboy_srq
@Richard Mayhew: I still worry that, given GOTea tactics of the last few years, proposing a deal will only be met with Teahadi demands for more concessions just to have the discussion, with more demanded in the talks (and nothing offered in return, per GOTea “compromise” logic) and an end result that gives away far more than necessary for far less than desired. I’d rather hold fast on the medical device tax and the HSA tax structure than risk losing major portions of ACA to Teahadi intransigence.
John
@everyone
I agree that Richard does a great job explaining, for the most part, and as someone who also works in healthcare policy I appreciate his ability to translate complex concepts into something more readily digestible.
This particular post, however, could have used more thought, better organization, and less jargon. I really did have to read it multiple times before figuring out what he was trying to convey.
DemJayhawks
My family fell into the family glitch for a few months. An unsubsidized silver plan for me and my three kids cost a little less than adding the four of us to my wife’s employer-provided plan. A subsidy would have made those few months when I was jobless much easier to afford.
RSA
@Richard Mayhew:
It’s an interesting exercise, because you present a picture of an imaginary Republican party that retains most of the same philosophical positions. The main difference is that they behave rationally, instead of the way they do now.
Richard Mayhew
@boatboy_srq: Then walk away — the you give,you give, we agree, and then you give some more tactic only works on must have items. Everything in this deal is a “nice to have” but not critical from a Democratic policy/political perspective. The next best thing to a negotiated agreement for a Dem is clear distinction of who supports improving PPACA and healthcare access and who does not. This is a clear distinction that works to Dem advantage in a presidential electorate.
Another Holocene Human
@Xantar: The media runs freakout stories like this every year and it’s a nothing burger every year. You’d think people would catch on.
No help from insurance commissioner in Florida, however. That office is on strike until Obamacare is abolished, so there, see how you like it. Oh, and no Medicaid expansion, so hospitals in big trouble. Good job, GOP.
Another Holocene Human
@SiubhanDuinne: Neigh goats.
rikyrah
You are writing logic, Mayhew.
They found nothing wrong with the old system.
Expecting them to come to the table with anything …well, fool’s errand.
Frankensteinbeck
True. The pattern with the Republican Party we have is that someone will propose it, it looks like the Senate would pass it, but the House either flat-out refuses, or demands a swathe of poison-pill changes. Nothing happens.
boatboy_srq
@Richard Mayhew:
Much more accurate. The modern GOTea seems prepared to do almost anything to prevent That Man achieving anything. Consider the sequester: lots of “must haves” that were done without for some time because the Teahad wasn’t going to give in. I agree with the principle – just concerned about the reality.
scottinnj
In a sane world would the employer mandate be on the table? The argument against the employer mandate (and from discussions with company this is an issue) is around the definition of a full time employee. Basically many companies keep their employees below a certain hours per week to avoid the mandate issues. Though many of them would also like to give their better employees more hours – which would be a good thing! I think the “JOB KILLING” aspect of the mandate is probably overstated but that doesn’t mean it is entirely untrue.