Yesterday, the U.S. House of Representatives narrowly passed the American Health Care Act, a bill to repeal and replace Obamacare. This was Republicans’ second attempt at doing so; the first stalled in March, after moderates were scared off by a Congressional Budget Analysis that found that the plan would eviscerate Medicaid, reduce subsidies to lower-income individuals, and leave twenty-four million more Americans uninsured; and hard-core conservatives complained that the AHCA left too much of the Affordable Care Act’s infrastructure intact.
The second go-round sought to appease the conservative camp by allowing states to opt out of Obamacare’s preexisting-conditions and essential-benefits mandates and allowing insurers to charge some sick patients higher rates. If they can’t afford their insurance, they’ll be shuffled off to a high-risk pool that is subsidized by the government; these, historically, have been underfunded and tended to come with long waiting lists. (To assuage moderates, the Republicans tacked on an extra $8 billion to help with high-risk premiums.) In any event, individuals in these pools would almost certainly pay more money for less-comprehensive insurance.
The bill passed 217–213, the House Republicans celebrated a rare victory at the White House, and the bill is now on to the Senate, where it’s likely to be significantly altered if not wholly rewritten before being kicked back to the House. At minimum, the Senate isn’t going to act without hearing from the CBO on the House’s revised AHCA, probably next week.
Last evening, after the vote, U.S. Representative David Price flew back into town, feeling, in his own words, “pretty bad about what happened.” His spirits were buoyed some by an event at Mystery Brewing in Hillsborough, Politics & Pints, where he was uplifted by the energy and enthusiasm and commitment of what has become known as the resistance. “I’m feeling pretty good about that,” he says.
Still, talking to Price—who has represented North Carolina’s Fourth Congressional District since 1988, minus a one-term interruption in the nineties—you can’t help but get the sense that he’s fed up and sick of it all.
“The process stinks,” he says. “It is absolutely out of line. Is there any precedent for this? There have been high-stakes votes before. I have never ever seen one undertaken with this little—this much of a violation of a process one should go through to figure out a major vote. Start with the absence of a CBO score. It is fundamental to know what the effects are—especially for something like this. The notion that you would proceed without any score, [without knowing] the number of people who would lose insurance!”
He continues: “Yet the couldn’t—they just did something. They wanted to force a vote before the facts were out. The so-called moderate members who represent the more moderate districts and know they have to pay attention to things—they’re very concerned about this. They succumbed to the pressure and cast a very bad vote.”
As Price points out, there were no committee hearings this week, no witness or expert testimony, and only three hours of floor debate. (Indeed, very few conservative wonks have defended the bill on policy terms.) The bill text wasn’t circulated until the day of the vote, and many of the Republicans who voted for the bill only seem to have a vague sense of what the bill actually did. The same goes for President Trump.
“This whole thing is a testimony to how low the legislative process has sunk,” Price says. “It’s a terrible commentary on the process.”
According to an analysis released by the N.C. Justice Center in March, Price’s district—which covers most of Raleigh and stretches out to Chapel Hill and up to Hillsborough—currently has 41,250 people enrolled in plans on the ACA marketplace. Of those, about 85 percent receive subsidies. Under the AHCA, those subsidies would disappear, many of them replaced by less-generous tax credits. (Since Obamacare became law, the uninsured rate in Price’s district has fallen by 24 percent.)
According to a report Price’s office released in March, North Carolinians would face the second-highest premium hikes in the country, behind only Alaska. The average Tar Heel would pay $5,921 more a year, plus another $1,628 a year in health care costs. (The N.C. Justice report pegs the average premium increase at a slightly lower $5,360.)
“These changes,” Price’s report noted, “will disproportionately impact lower-income, older North Carolinians.” Younger, wealthier residents, on the other hand, will see their rates go down.
If anything, Price says, the bill that passed yesterday is worse than the one that didn’t in March.
“The effect on North Carolina is extreme,” he says. “We’re second only to Alaska. This insurance for many many people would become unaffordable. What the new bill does is introduce a radical uncertainty. … Would North Carolina [seek a waiver]? If they didn’t opt out, what I said holds. If they do, you really do open up a wide range of bad possibilities. There could be a race to the bottom in terms of what insurance companies offer. You could have the market flooded with inferior plans—could be cheaper plans, but they could have everything from lifetime limits to all sorts of omissions, and guaranteed issue goes away. What happens to those people? There has to be a high-risk pool. We know they’re not adequately funded in this bill. You can predict uncertainty and a bunch of bad options.”
Now the bill is headed to the Senate, where moderates would appear to have more sway and “senators don’t like in the same kind of bubbles” as House members, Price says. Even so, “I don’t take much comfort in all this.” The Senate leadership has proven itself ruthless and it, like the House, is under pressure to score a win for the boss.
“They’re under pressure to get together with the House and pass something pretty awful,” Price says. “That’s exactly why they had the vote yesterday—there’s a recess this week. There was a lot of speculation about why the bill failed the first time. One of the underlying reasons was the degree of protest in the districts. I think it really matters how much community outcry and pressure there is. The pressure does matter on this. Everybody is an expert on health care. Everybody has a stake. Everybody knows somebody who has an even more desperate stake. The extent that House members get blowback on this and senators read the writing on the wall, that’s going to make a huge difference.”