To pass health-care reform, Republicans may strip it down
IT HAS become a fool’s errand to try to predict when the Republicans may give up trying to reform health care. On July 25th Vice-President Mike Pence broke a tie in the Senate to pass a motion to start debate on a health bill, only a week after it had looked dead (and not for the first time). 

IT HAS become a fool’s errand to try to predict when the Republicans may give up trying to reform health care. On July 25th Vice-President Mike Pence broke a tie in the Senate to pass a motion to start debate on a health bill, only a week after it had looked dead (and not for the first time). To win the vote Mitch McConnell, the leader of the Senate, had to water down its significance, portraying it as merely a procedural step that had no bearing on what might subsequently pass. (“Everybody will get a vote on everything they want to vote on,” said Senator John Cornyn, Mr McConnell’s number two). Even then, the motion passed only because Senator John McCain, just out of surgery for brain cancer, rushed back to Washington to vote yes.

The result is a mad rush to rewrite the bill on the Senate floor. The starting point is the version passed by the House in May. After voting to start debate, nine Republicans rebelled to defeat an amendment turning the bill into the “Better Care Reconciliation Act”, the reform Mr McConnell had painstakingly crafted. (In any case, the Senate’s rules expert had declared that parts of the BCRA needed 60 votes, and hence Democratic support, to pass.) The next day, seven Republicans helped Democrats reject the Obamacare repeal bill that Congress passed back in 2015 (it was vetoed then by Barack Obama). Moderate Republicans oppose total repeal because it would deeply cut Medicaid, health insurance for the poor, and abolish the tax credits which help low- and middle-income people buy insurance on online marketplaces, or exchanges.

As a result, Republicans may resort to what has been dubbed “skinny repeal”. This amendment would take a scalpel, rather than an axe, to Obamacare. Medicaid expansion would stay, as would the law’s regulations and tax credits. Instead, the bill would probably repeal only those parts of Obamacare Republicans dislike most: its “mandates”. These impose fines on people who choose not to buy health insurance, and on large employers who do not provide insurance for their staff.

Moderate Republicans may find skinny repeal easier to support, because it would leave Medicaid intact. But failing to replace the individual mandate would greatly threaten the stability of the market serving 18m Americans who buy insurance for themselves. The Congressional Budget Office has suggested that killing the mandate would increase the number of people without health insurance by 15m by 2018. Nonsense, say conservatives. But without the mandate, it would certainly be easier for people to flee the individual market’s high premiums, caused by Obamacare’s ban on insurers discriminating against buyers who are already ill. The likely result would be more premium increases, a still smaller market, and the very “death spiral” that Republicans say they want to stop.

A collapse of the individual market would hardly look good for those in power (although President Donald Trump has spoken of his desire to kill off Obamacare in an attempt to force Democrats to support a replacement). More likely is that the bill gets rewritten again in the committee that would have to reconcile the bills passed by the House and the Senate. Health reform could seem to die, only to be resurrected, a few more times yet.