At some point in their efforts to repeal the Affordable Care Act, Republicans started saying that they wanted to not only repeal but also replace the law with something better. But mostly, when asked what the replacement would be, Republicans have offered few specifics and only a few pitifully vague adjectives — “patient-centered,” “less intrusive” and other relatively meaning-free words and phrases.
Perhaps that has changed. Three Republican senators — Tom Coburn of Oklahoma, who is a physician, Orrin Hatch of Utah and Richard Burr of North Carolina — have introduced a bill that would repeal the Obamacare law and replace it with they are calling the “Patient CARE Act.” (CARE is an acronym for “Choice, Affordability, Responsibility and Empowerment.”)
It’s too soon to call it the Republican offer to replace Obamacare, since the party has not embraced it. But I expect it will pick up co-sponsors and it could become the vehicle for Repubs to argue that they do too have a plan. Forbes magazine has called it “the most thoughtful and constructive plan yet developed to repeal and replace Obamacare.” It picks some features of Obamacare, slims down others, and drops quite a few.
I can’t grasp all the moving parts. But here are a few. There is no individual mandate requiring the uninsured to get insured (or pay a fine). There are no “exchanges” to enable individual shoppers for health insurance to compare plans. PCARE would (as Obamacare does) expand the eligibility for Medicaid, but not as much. So some families on the border of poor and working class would be left out. Mandating that kids can stay on their parents’ policies until 26 and a ban on lifetime caps would both stay in the law.
The ban on insurance companies refusing to accept those with pre-existing conditions is mostly gone, although if you already had insurance when you developed such a condition, your insurer couldn’t drop you or raise your premiums. Obamacare offers tax credits to help families afford health insurance. PCARE would too, but would change the income-boundary for who gets the credit (thus fewer families would be eligible for that form of subsidy).
A big and perhaps surprising difference (given the general Republican attitude to tax increases) is that PCARE introduces a large new tax on those who get insurance through their jobs. Under current law, those employees don’t pay any income tax on the money their employers pay to insure them. Under PCARE, employees would pay income taxes on 35 percent of the employers’ contribution. For middle- and especially upper-middle-class families, this would probably be a significant tax hike.
Well, I’d better stop there for now. It’s clear to me that more people would end up without insurance. It is still a big new “intrusion” of government into the workings of the private health-insurance market, but not nearly as big as Obamacare. It seems possible, even likely, that some movement in this direction could have been negotiated in 2009-10 if Republicans had offered to support a compromise law instead of deciding to all vote against the ACA so they could then forevermore denounce the law on the grounds that it received no Republican votes.
There are several summaries with more details. I relied on this one by Ezekial Emanuel from the New York Times op-ed page. Here’s one from the libertarian magazine Reason, written from a viewpoint sympathetic to the Coburn law.