Senate Republicans are showing early divisions over what to do about Obamacare’s protections for people with pre-existing conditions.
Some conservatives, including Sen. Mike Lee (R-Utah), want to simply repeal those provisions and other ObamaCare regulations and leave them up to the states.
But advocates of a more centrist approach, like Sen. Bill Cassidy (R-La.), are speaking out in favor of pre-existing condition protections and endorsing a “Jimmy Kimmel test” for the bill, where no one can be denied coverage.
Other senators are exploring a middle ground where states would have to automatically enroll people in health insurance before they could get a waiver for the regulations, though conservatives object to that idea as Washington overreach.
The disagreements over what to do about preexisting conditions point to the larger difficulty facing Senate Republicans as they seek to find consensus on a host of contentious issues in the healthcare bill.
Still, many Senate Republicans are open to allowing states to repeal at least some of the Obamacare regulations, which are located in Title I of the law, including the provision that people with pre-existing conditions cannot be charged more.
The House’s version of the bill includes a provision along those lines. It came in the form of an amendment from Rep. Tom MacArthur (R-N.J.) that stirred controversy but was critical for winning support from the conservative House Freedom Caucus.
Senate Republicans are divided over whether to allow states to opt out of the regulations, meaning they would have to meet certain conditions to be granted a waiver, or opt in, an option favored by conservatives that would leave repeal of the regulations as the default option unless a state takes action.
“We want an opt-in not an opt-out approach to the Title I regs,” said an aide to a conservative senator. “Unfortunately, it seems many want an opt-out approach contingent on states adopting auto-enroll before any waivers can be granted.”
Among the regulations at issue are Obamacare’s “community rating” provision, which prevents people with pre-existing conditions from being charged higher premiums due to their health, and “essential health benefits,” which mandate that insurance plans cover a range of services like mental healthcare and prescription drugs.
Conservatives argue those regulations are driving up the cost of premiums.
Cassidy, though, is the author of a bill that would leave many of the regulations in place.
Asked about allowing states to repeal rules preventing people with pre-existing conditions from being charged more, Cassidy cited statements from President Trump.
“The president’s been pretty adamant that he wants to take care of people with pre-existing conditions, and I’m not sure that particularly cares for people with pre-existing conditions,” Cassidy said.
One idea that has been discussed in the Senate Republican working group on healthcare is to allow states to waive some of the ObamaCare regulations if they agree to auto-enroll people in their state in a health insurance plan. Under that idea, people would be automatically enrolled in a bare-bones health insurance plan along with a tax credit to pay its cost, unless they actively opted out.
Automatic enrollment would be one way to try to get more healthy people in the system without ObamaCare’s unpopular mandate to get insurance.
But conservatives object strenuously to the auto-enrollment idea.
“Enrolling people without their consent is a giveaway to insurers that inflates prices, drives up costs for taxpayers, and keeps Washington at the center of health care,” two conservative groups, Freedom Partners and Americans for Prosperity, wrote in a letter to Senate Republicans on Monday.
The aide to the conservative senator called auto-enrollment “a significant step towards socialized medicine.”
Other aides cautioned that there has only been a general discussion of auto-enrollment and not a push for it yet.
Some senators are in favor of repealing Obamacare’s regulations if money for high-risk pools is increased. Republicans argue that high-risk pools could step in to provide coverage for people with pre-existing conditions, but Democrats counter that they were seriously underfunded when tried before Obamacare.
Sen. Mike Rounds (R-S.D.) said he and other senators have proposed to leadership that an actuary be brought in to consult them on how much funding will be needed for the high-risk pools to function well.
“It appeared as though the numbers they talked about in the House were probably considerably lower than what they needed to make it actually work,” Rounds said. “All we want is an honest estimate that an actuary would look at and say, ‘This is reasonable.’”
Another potential problem is that repealing Obamacare’s regulations might not be possible under Senate rules governing the fast-track process known as reconciliation. Republicans are using that process to bypass a Democratic filibuster and pass the repeal bill with a simply majority.
Under those rules, provisions must be related to the budget to be included in the bill. Sen. John Cornyn (R-Texas) said earlier this month that lawmakers were “looking at” whether the essential health benefits regulation could be repealed under the process.
Sen. Ron Johnson (R-Wis.), who has attended some of the Senate working group meetings, argues that all of Obamacare could be repealed under the rules because the regulations drive up premiums, which in turn drives up government spending on subsidies.
“Personally, I think we could repeal the entire healthcare bill, because all those market reforms are tied to premium increases which affect subsidies; they’re all budget related,” Johnson said.
Asked if his colleagues in the working group agreed with him, Johnson said: “I think we have differences of opinion in terms of that, so that’s my opinion.”