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This Insider Explains Why The Obamacare Debate Is Such A Mess


Since Tuesday afternoon, when the U.S. Senate voted 51-50 on a motion to proceed, Washington has been consumed with wall-to-wall health care reform coverage; a rumored Friday vote on the Senate floor looms large. The most significant accomplishment of President Barack Obama hangs in the balance: the Affordable Care Act (ACA), a.k.a. “Obamacare.”

For Grace-Marie Turner, this presents the chance of a lifetime. As head of the Galen Institute, for two decades she’s brought together diverse conservative factions to find consensus on what free-market health care reform really looks like. Called “the most influential conservative health care scholar in America” by Avik Roy—himself a rising star in policy circles—Turner regularly briefs Members of Congress on health care issues and serves as general editor of the website ObamacareWatch.

In a wide-ranging interview, Turner discusses the CBO’s “magical” estimates in favor of the ACA, an eye-opening story from an Uber driver she met recently, and how soon Americans could expect to see lower insurance premiums.

The Federalist: Assuming a successful Senate vote within the next couple days, do you expect the health care reform effort in Congress will lower the cost of buying health care insurance?

Grace-Marie Turner: The cost issue is so primary. Members of Congress know that lowering costs is the first thing the American people wanted before the Affordable Care Act passed, and what they want Congress to do now. Obviously, as we all know, the Affordable Care Act dramatically increased prices—the cost of family policies is up by 140 percent.

Many people get subsidies to help offset the cost, but, number one, somebody’s paying for that—namely taxpayers. And number two, there are millions of people who do not qualify for subsidies who are having to pay the full cost of these much more expensive policies.

People are rightfully angry, and I think they’re especially angry because they feel they were lied to. One of President Obama’s key promises was that the average family would see its health insurance costs drop by $2,500 per year. Not only have costs not dropped, they’ve gone up by more than that amount.

Whether or not the bill that emerges from the Senate actually deals with the cost issue, it’s impossible to know yet. We do know that is one of their primary goals. It’s also one of the goals Senator Ted Cruz has tried to achieve by giving people the option to purchase a greater variety of plans that actually suit their needs.

TF: Speaking of presidential promises, some conservatives want a full repeal of Obamacare. Is that possible with the current party dynamics in the Senate?

Turner: It’s not possible, because of how the party dynamics required choosing a certain process for this bill. Usually in the Senate, we have to have 60 votes to get a bill through regular order. By using the reconciliation process, it’s a 51-vote margin, but they’re very limited in what they can push through that narrow channel.

Only things that directly affect taxing and spending, federal budget issues, can be part of this bill. It’s not possible to repeal the whole of Obamacare with 51 votes. There are 52 Republican Senators currently, but as we saw in Tuesday’s vote, they lost two of them—thus, Vice President Mike Pence had to break the tie. They have no margin to spare.

Frankly, after so many millions of people are getting subsidies and getting insurance through the ACA, they don’t want to yank the rug out from under people. They don’t want to repeal the whole thing. The reason they’ve been so hung up all year is that they’re trying to figure out, What is the replace plan? How do we lower costs? How do we give people more choices? How do we make the health system better? Again, using this narrow reconciliation process—it’s a very difficult project.

TF: Surely there are some Democratic Senators who want to work on bipartisan fixes to Obamacare. Why are they not coming to the table?

Turner: That’s actually what Senator Chuck Schumer said in an impassioned speech before Tuesday’s vote on the Senate floor: “Let us work in a bipartisan nature.” But sadly it’s disingenuous. Their bipartisanship means that the ACA stays in place and that you just add more money to it, or you create new regulations to force even more people to purchase coverage they don’t want.

The bipartisanship really is difficult because of the different ideologies we bring to the table. The words sound nice—and the Senate may wind up going there. But at that point “reform” is going to mean minor tweaks around the edges. We would end up having Obamacare forever if they move towards a ‘bipartisan’ process.

TF: The nonpartisan Congressional Budget Office has estimated that 22 million fewer people will have health insurance within a decade, if the Senate bill were enacted. Are the CBO estimates concerning to you—and if not, why not?

Turner: The CBO’s estimates have been widely discredited. They have this assumption that, if we just wait long enough, the individual mandate is going to finally work—like magic! Millions of Americans are currently ignoring the mandate: not getting health insurance, not paying the fine, and not reporting that they don’t have health insurance.

The CBO assumes that the individual mandate is such a powerful force requiring people to get coverage, eventually we’re going to get to their estimates of 25 million people under the ACA. It’s not going to happen! The more expensive health insurance gets, the less likely people are to purchase it.

People think, ‘Oh no, Americans are going to lose their coverage.’ That is completely bogus! The CBO basically assumes a baseline of about 20 million people that would ‘lose’ coverage because people wouldn’t be forced to buy it. They assume that five million people will drop their Medicaid coverage simply because the individual mandate has gone away, even though Medicaid is free!

Then the CBO assumes five to six million people would drop their employer coverage, because the mandate goes away, and the same thing with exchange coverage. It’s not based in the reality of current numbers for health insurance coverage, nor in the reality of where we would be in the future if the mandate stays in place.

Polling consistently shows that the individual mandate is the least popular part of Obamacare, by the way. Yet the entire structure of this law is built around it, and it’s a key pillar in the CBO estimates.

We were just discussing bipartisanship. The individual mandate is not something the Democrats would ever let go of. As a result, they are building on a structure that is much more federal government-centric than the American people clearly want in the health care sector.

TF: What main goals should Congress be pursuing with this bill?

Turner: Congress really has to do four things in this bill. First, they have to create a safety net for people who are currently on ACA coverage. Second, they’ve got to do something with costs so people can afford coverage.

Third, they’ve got to give states more power and authority to be able to regulate and oversee their own health insurance plans—because the federal government has proven it’s completely out of its league in regulating something as local as health care.

Lastly, they need to reform the awful Medicaid program that is costing so much money and providing such poor care to tens of millions of people. Governors need new tools to be able to better manage their Medicaid programs. Those are four things this legislation needs to do.

TF: Do you expect the final health care reform bill will have robust coverage for low-income Americans with pre-existing conditions, through Medicaid funding or other means?

Turner: Yes, if Congress does a comprehensive bill. That has certainly been the goal in all the major pieces of legislation so far—to provide generous coverage and do it in a way that gives states more power to target funds to people who most need help purchasing coverage, whether it’s public or private plans.

If they do a skinny bill, then there are no new coverage provisions. They have recently discussed a scaled-down bill that gets rid of the individual mandate, the employer mandate, and the medical device tax. In that case, they’d have to come back to major health care reform.

TF: Earlier you mentioned Senator Ted Cruz’s amendment on the Senate health care bill, which has gotten a lot of attention. Could you explain this proposed policy?

Turner: It’s been interesting to see this evolve. Senator Cruz was determined to figure out how to thread the reconciliation needle to be able to give people better choices for health insurance policies.

What he wants to do is give people the option to buy coverage with ACA subsidies, but not with the constraints and requirements that are currently required. Rather than having the federal government dictate what coverage had to be in policies, the Cruz amendment allows consumers to determine the benefits they want and still shop for insurance policies on the Obamacare exchanges.

Many people have found Obamacare policies are too comprehensive for their needs, and they can’t afford it. Senator Cruz had to shape it in a way that would work through the Senate process, though we have yet to see how the parliamentarian will rule on this amendment.

TF: When looking at the House and Senate efforts so far, many on the left contend that it gives tax breaks to corporations and the wealthy, on the backs of average Americans. How do you respond?

Turner: Average Americans have been the most disadvantaged under the Affordable Care Act. People are now forced to purchase health insurance that actually can be more expensive than their mortgage!

I recently met an Uber driver in Washington, D.C. He told me he had to work this second job to pay the health insurance premiums, which are $1,500 per month for his family. He told me, “There’s no way I can afford that!” He was respecting the fact that there is a mandate, his job did not provide coverage, and he made too much money to qualify for subsidies in the exchanges—so he had to buy a policy for $1,500 and he had to get a second job to do that.

The American people need relief from Obamacare. That’s one of the reasons this law has been so consistently unpopular. Apparently one of the things that’s now more unpopular than Obamacare, though, are Republican plans to fix it. But I think that’s because they’ve done such a poor job of messaging and really helping people understand what’s in their proposals.

TF: There’s a lot of fear surrounding something as personal as health care—fear of poverty, of corporations, or of distant politicians deciding one’s fate. How can leaders instill confidence in people about these reform efforts?

Turner: They have not so far, partly because the American people have such a basic distrust of government. They know that whenever government does anything, it’s probably going to cost more money and take away their choices. And what we’ve seen in recent years validates that fear.

There’s a wonderful quote by Princeton professor Paul Starr, who wrote a book called “The Social Transformation of American Medicine” for which he won the Pulitzer Prize. He said, “Politicians since Bismarck have used insurance against the cost of sickness as the means of turning benevolence into political power.”

People are frightened, and legitimately so, about having medical bills that would be so expensive that it would bankrupt them, or that they would not be able to get the care that they or their family members need because they didn’t have insurance. People want health insurance that they can afford; that’s really the challenge for politicians.

The fear issue is primary. People are driven by fear of the economic consequences of not having health insurance and they want it—but they don’t want it at the expense of other freedoms, including economic freedoms we have in this nation.

TF: Assuming a bill passes in September—the final conference bill hashed out by House and Senate leaders—how soon would you expect Americans will begin to see a drop in monthly health insurance premiums?

Turner: That’s really the question. Members of Congress want people to see a drop in their health insurance premiums next year. It’s an election year—that’s always motivating for political leaders.

But it’s very difficult, because most insurance companies have already submitted their policies and rates for next year. This is one of the reasons that Senator Ted Cruz is trying to give people other options through his amendment.

I think it’s going to be difficult for people to see an immediate drop in their premiums, but there’s going to be a sense that there is more stability—at least they won’t be seeing premiums go up by 50 to 60 percent, which is what they are scheduled to do now if nothing happens.

TF: Some have criticized President Donald Trump for being disengaged from the debate over health care reform. What is your perspective?

Turner: He has been tirelessly working to try to get this legislation through. It’s true that he’s not ever going to be the guy like former President Bill Clinton who gets down into policy details.

But President Trump has done absolutely everything he and Congressional leaders can think of—from doing speeches, to personal phone calls, to inviting Senators over to the White House for a luncheon last week to talk with them. He’s listened to them and asked, ‘What do you need in this to be able to vote for it?’

Maybe people don’t think he’s as effective as he could be in describing what’s actually in the bill, but even that he’s tried. He’s done everything! The President is trying very hard to convince people that they need to get this over the finish line.

TF: Considering our nation’s opioid epidemic, rising prescription drug costs, and related issues, do you expect Congress will take up other health care reform bills later this year?

Turner: Leaders in Congress have a three-part plan for health reform. The first piece is to repeal and replace Obamacare through reconciliation, and I now believe that they will get something through.

The second piece is giving people regulatory relief. Dr. Tom Price at the Department of Health and Human Services has already worked hard to issue and review regulations—based on one of the President’s first executive orders—to ensure that people are given relief from the costs and impacts of Obamacare.

The third bucket is to be able to pass a series of individual regular-order bills, some of which should be able to get bipartisan support. They want to move forward things like allowing veterans to use their tax credits to be able to purchase health insurance and ending the Independent Payment Advisory Board, which has been given unprecedented powers.

There are some things the House has actually already passed and sent over to the Senate, such as medical liability reform. The main thing is getting this first piece done so they can move on to giving people relief in other ways.