Today in Obamacare: here’s why it’s so hard for Republicans to agree on replace

One key reason Republicans are in disarray over the future of Obamacare

In some ways, the current Republican disarray over health care is reminiscent of where Democrats were in 2009. They had lots of different policy papers floating around and significant infighting over which one they should choose. (Exhibit A: the constant battle over whether to include a public option, best summarized in this 2009 video featuring a sock puppet Joe Lieberman.)

Lately, though, I’ve started to think there is something very different about the Republican disarray we’re seeing now, in the leaked audio from the party’s retreat last week.

I think we’re seeing something that makes it much harder for Republicans to coalesce around a particular policy.

Even when Democrats were split on how to expand coverage in 2009, they still were all working toward the same goal. They all agreed that whatever bill they came up with should lead to millions of Americans gaining coverage, particularly the type of people who had struggled to obtain coverage in the past (people who are older and sicker generally). There was a key principle at the heart of the party’s policymaking.

But Republicans don’t seem to have this — it’s not clear what particular objective their policymaking is striving toward, aside from dismantling the Affordable Care Act. Sometimes their words and their plans point in opposite directions.

You would think from the rhetoric of conservative legislators that the problem is what people have to pay out of pocket: that the deductibles under Obamacare are far too high.

“Many people who have insurance can’t even use it because they have $10,000 or higher deductibles,” House Majority Whip Steve Scalise told Fox News this weekend. Rep. Tom Price (R-GA) lamented in his confirmation hearing for Health and Human Services Secretary that “you have deductibles that have escalated to $6,000 to $12,000.”

Or as President Trump put it to Sean Hannity last week: “The deductibles are so high that unless you get hit by a tractor, you will never be able to use it.”

The rhetoric is incredibly unified on this issue: Cost sharing under the health law is far too high. But the actual policies Republicans are developing move in the opposite direction. They don’t do anything like limit the size of deductibles in the marketplace, or cap out-of-pocket spending. Instead, most envision high-deductible health plans as an even more prominent part of the health care system.

Most Republican proposals include more high-deductible plans paired with health savings accounts, where consumers would deposit tax-free dollars (or receive some credits) and do their best to keep their medical spending within whatever amount they set aside. House Speaker Paul Ryan lays out the idea in his “A Better Way” health care proposal:

Consumer-driven health care allows individuals and families to control their utilization of health care by providing incentives to shop around. Republicans have long supported expansions to these popular arrangements, especially HSAs. HSAs are tax-advantaged savings accounts, tied to a high-deductible health plan (HDHP), which can be used to pay for certain medical expenses.

There are definitely policy reasons to support the use of high-deductible plans, which make consumers more cautious about going to the doctor — and, like Ryan says, encourage patients to shop for cheaper doctors. There are reasons to be cautious about them, too, as they could make necessary health care too expensive for vulnerable populations.

This is a debate we could be having about health care: about whether it would be better to make the overall cost of the law cheaper by moving toward high-deductible plans. You could envision a world in which Republicans say the government ought to take less of a role in health care and Americans have to become better shoppers as they face high-deductible plans.

But this isn’t what is happening — Republicans don’t seem, right now, to be working toward the goal of lowering deductibles or expanding coverage or anything else. They’re working toward the goal of repealing Obamacare, without a particularly clear vision of what exactly comes next. Until Republican rhetoric and policy come into line, it will be awfully hard for the party to come to any kind of consensus.

Graph of the day

Morning Consult is the third polling firm to find Obamacare popularity increasing as chatter of repeal gets louder. This is also the most granular breakdown of whose opinions have changed that I have seen. The other polls are NBC and Fox News.

Another notable poll that came out last week from the Associated Press found that 56 percent of American adults are "extremely" or "very" concerned that many will lose health insurance if the ACA is repealed.

Kliff Note’s: today’s top 3 health policy reads

“Trump's actions on Obamacare threaten to undermine insurance markets”: “Senior Republicans have been pressuring health insurers to publicly declare that Obamacare is failing, according to industry officials. A number of health plan leaders told congressional Republicans that they would not say that, said the officials, who asked not be identified for fear of antagonizing the GOP.” —Noam Levey, LA Times

“Last call for 2017 Obamacare insurance coverage”: “You have until Tuesday, Jan. 31, to apply for 2017 coverage through state and federal marketplaces. More than 11.5 million people have signed up for insurance through the exchanges as of Jan. 10.” —Dan Mangan, CNBC

“The simplest path to repealing and replacing Obamacare”: “They should agree that whatever else is in their upcoming Obamacare bill, that it include one measure: a provision to freeze new enrollment in Obamacare. That is, they could continue allowing those who have benefits to receive them, but then prevent anybody from enrolling in the law's expanded Medicaid program who was not already on the books as of the date the bill is signed into law. Additionally, nobody would be eligible for subsidies for Obamacare's exchanges who did not already sign up for coverage by Jan. 31 — the last date of open enrollment for this year.” —Philip Klein, Washington Examiner

Join the conversation

Are you an Obamacare enrollee interested in what happens next? Join our Facebook community for conversation and updates.

Will you support Vox today?

We believe that everyone deserves to understand the world that they live in. That kind of knowledge helps create better citizens, neighbors, friends, parents, and stewards of this planet. Producing deeply researched, explanatory journalism takes resources. You can support this mission by making a financial gift to Vox today. Will you join us?

One-Time Monthly Annual

$5/month

$10/month

$25/month

$50/month

Other

$

Yes, I'll give $5/month

Yes, I'll give $5/month

We accept credit card, Apple Pay, and Google Pay. You can also contribute via