When House Speaker Paul Ryan and President Trump tried to repeal and replace the Affordable Care Act, they found themselves under assault from two directions. On one side, their bill was spectacularly unpopular with the public at large, mostly because it would have tossed tens of millions of Americans off their health coverage and made everyone else's coverage less secure (one poll found the GOP's American Health Care Act supported by only 17 percent of the public). On the other side, the House Freedom Caucus — a collection of the most extreme conservatives in Congress — was angry that the bill wasn't nearly as harsh as they might like.
When the bill died, more than a few Republicans breathed a private sigh of relief. The debate had taught them not only that reforming health care is extraordinarily complex and can require months or even years to do properly (or in President Trump's immortal words, "nobody knew that health care could be so complicated"), but also that their vision of a health-care system guided less by security and more by "freedom" and "choice" turns out not to be what the public actually wants. Perhaps it would be best if they just left it alone and moved on to issues like tax reform, which they care more about anyway.
But like a villain in a B-grade horror movie, the Republican health-care plan is rising from the dead, uglier and more threatening than ever.
When Democrats passed ObamaCare in 2010, one of their central goals was to bar insurance companies from denying coverage to people because of pre-existing conditions. That practice left tens of millions of Americans living in perpetual uncertainty, knowing that they either couldn't get coverage at all or could only get it if it excluded the things they'd probably need treatment for. It led to widespread "job lock," in which people who might have started new businesses or joined a small company couldn't do so because they had to stay in their old job to hold on to the coverage they had.
So the Affordable Care Act told insurers they had to insure everyone, and charge them the same rates no matter their medical history (the latter is known as "community rating"). To make it possible for insurers to do so, the law also sought to expand the risk pool by requiring everyone to carry insurance.
Republicans hate that requirement (the individual mandate), and want to get rid of it. But they discovered, much to their chagrin, that the ban on denials for pre-existing conditions is hugely popular. Now that it's in place, it's extremely hard to snatch away, since almost no one wants to go back to the bad old days. What to do? In the first version of their repeal plan, they kept the ban but included some convoluted provisions meant to encourage people to get insurance, and not just wait until they got sick to sign up, but they were wholly inadequate to the task.
In the latest version — meant to appeal to the Freedom Caucus members who didn't support the first bill — they've said goodbye to the ban on denials for pre-existing conditions. Welcome back to the days when you had to tell your insurer every time you've visited a doctor for years prior, and had them scrutinize you for the things they don't want to cover.
Okay, okay — that's not precisely true. Republicans would keep the ban on denials for pre-existing conditions on paper, but make it disappear in practice. According to reports emerging from the negotiations, the White House is appealing to the Freedom Caucus by offering to allow states to opt out of community rating, which means that after poring over every detail of your medical history, your insurer could say, "We'll give you coverage. But since you had that knee surgery (or that heart attack, or that diabetes, or that psoriasis), your premium will be $20,000 a month." It would be easy for insurers to charge such exorbitant rates to those with pre-existing conditions that they'd never have to insure someone who wasn't healthy. Not only that, if you started off healthy and then got sick, they could raise your premiums so high you'd no longer be able to afford insurance.
Another provision the White House has offered is to eliminate the "essential health benefits" that insurers are now required to cover, things like emergency services, prescription drugs, hospitalization, and maternity care. It would once again allow the sale of policies that cover basically nothing, so that consumers would be tricked into buying a plan by its low premiums, only to discover once they needed it that their insurance isn't really insurance at all.
That's the appealing new health-care world Republicans are considering bringing us into: crappy insurance, and tens of millions of Americans with pre-existing conditions getting utterly screwed. How popular do you think that will be?
Which leads me to a crazy theory: Maybe Republicans know that this new plan will get an even more hostile reception than the old one, so they're floating it out there as a kind of lead trial balloon. They'll watch the disgusted response, say, "Well, we need to think about this some more," and then put the issue off indefinitely.
We should be so lucky.