On Monday three Republican Senators,Tom Coburn, Orrin Hatch, and Richard Burr, released a legislative proposal to repeal and replace the Affordable Care Act titled “The Patient Choice, Affordability, Responsibility, and Empowerment Act” (PCARE). The outline is generally considered the most comprehensive effort by conservatives to fulfill the years-long promise of a serious replacement plan to follow repeal of the president’s health care law. While those on the left may find little or nothing to their liking (not that it was written for them), there are a few surprising features.
For one, it doesn’t really repeal Obamacare. This might be confusing considering that the first and only section of the first title is, in fact, to “Repeal Obamacare.” But as Duke University public professor Don Taylor notes in his quick response the rest of the Act actually “locks in a good deal of the structure of the ACA, and addresses changes from that new status quo.” If you’ve been paying attention to numerous attempts to repeal Obamacare in the past couple of years this is a comparative sea change in conservative orientation towards the law. It’s also one that, even if the contents leave much to be desired, is an encouraging step towards taking health care reform seriously.
The short version is that PCARE wouldn’t so much treat the existing legislated structure of the ACA as status quo as it accepts the legislative aim for reforming health insurance. So their plan includes specific initiatives to address: affordability through tax credits (though not through the ACA exchanges, which would be gone); expanded coverage through regulation that ensures guaranteed issuance (but only through a decidedly hazy attachment to ‘continuous-coverage’ that would effectively rollback the ban on denial preexisting conditions); and getting people to sign up by removing that guaranteed issuance protection when people purchase outside of some unspecified open-enrollment window. It would keep some regulations, like an age-band (albeit widened from 3:1 to 5:1) for what insurers can charge based on your age, still require insurers to offer coverage for dependents under age 26, and keeps the ban on lifetime limits.
That being said, this is still a Republican plan. So like other Republican plans since 2010 it is much less generous than what Obamacare is trying to achieve, and includes components (like tort reform) that health care experts would generally see as having more bark than bite in its ability to effect substantial change in the health care system. The tax credit eligibility is lowered from 400 percent of the poverty line to 300 percent ($45,960 versus $34,470 for an individual), and broken up into age brackets. It still assumes Medicaid is terrible because it doesn’t pay doctors enough, but then doesn’t actually have a position to improve that reality, while paring back the expansion to exclude childless adults. Yet if PCARE was proposed during the administration’s feverish attempt to get a handful of Republican votes in 2009 then conservatives probably could have gotten quite a bit in the negotiations.
Sarah Kliff has an excellent overview if you want more. For those interested in the minutiae of health care reform there’s certainly more details to discuss, especially the financing portion related to capping the tax exclusion for employer-provided insurance (which would be hella-disruptive, by the way, and would make those folks pay a lot more for their insurance). For the rest of you though the key takeaway is that PCARE represents, some would argue a return to, seriously confronting the issue. Moreover, that this is a level of seriousness that is even recognized on the right.
If you subscribe to the idea that future reform will necessarily depend on a compromise between both parties, and where one party doesn’t assume that repealing Obamacare is enough, then this is a good development. As Don Taylor wrote there is more in this plan that could, at the very least, be talked over. Essentially it is a small policy jump over a tiny hurdle, but meaningful in the sense that a jump has occurred in the first place.