The Senate Health Care Charade


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Illustration by Joan Wong; Photo by Doug Mills/The New York Times

It is tempting to think that the Republican health care proposal, which would do so much damage to so many Americans, will collapse in the Senate, since conservatives and centrists alike have come out against it. But that would be premature. After all, House leaders managed to cobble together a narrow majority for their bill after similar protests in that chamber.

At least some of the Senate opposition to Majority Leader Mitch McConnell’s opening bid in the health care wars is mere political theater. Far-right senators who are protesting that the bill does not do enough to get rid of the dreaded Affordable Care Act, or Obamacare, are almost certainly posturing. These lawmakers want to be seen as making the bill more extreme to burnish their conservative bona fides. But they do not want to be blamed for blocking legislation that by any objective analysis achieves the Republican goal of destroying the A.C.A. and more. It would greatly weaken Medicaid, a program that many in the party have long despised. And it would leave more people uninsured than if Congress repealed Obamacare without putting anything in its place, according to a recent analysis by the Urban Institute.

Senator Ted Cruz of Texas has already floated a potential compromise that could get him and at least one more conservative, Mike Lee of Utah, to vote for the bill. His proposal would let insurers sell two different kinds of policies: ones that meet the requirements of the A.C.A. and ones that do not. The idea is to let younger, healthier people buy skimpier, cheaper plans that do not cover many medical services and that have very high deductibles. Older and sicker people would be able to buy plans that are more comprehensive.

But experts say dividing the insurance risk pool in this way would force insurers to raise premiums a lot, because plans that cover more services would primarily attract people who have more health problems. Many middle-class families would not be able to afford those plans, since they earn too much to qualify for subsidies. This so-called compromise smacks of the kinds of changes demanded by the Freedom Caucus, whose members objected to Speaker Paul Ryan’s original bill in the House. As a result of their demands, the measure passed by the House would let insurers discriminate against people with pre-existing conditions.

In reality, the lawmakers who will make or break the Senate bill are centrist Republicans and lawmakers who represent states that expanded Medicaid under the A.C.A. This group includes Susan Collins of Maine, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado, Dean Heller of Nevada, Lisa Murkowski of Alaska and Rob Portman of Ohio. Mr. McConnell, President Trump and other Republicans are putting lots of pressure on them — and are trying to win them over with modifications that may seem like improvements but do not change the bill’s substance.

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