Is the House Obamacare replacement bill an early April Fool’s joke?

The long national health care nightmare is over.  As promised for years by congressional Republicans and by President Donald Trump, Obamacare is in its final season.  No next season.  Only reruns playing on a continuous loop in the future Obama Presidential Library.

On Monday, the House of Representatives released the long anticipated Obamacare repeal and replacement bill.  Let's take a look at a few of the key provisions.  Is this the replacement that we have been waiting for, or is it an early April Fool's joke?

The House bill kicks the knees out from Obamacare – specifically, subsidies to purchase insurance, Medicaid expansion, and mandates that everyone purchase health care insurance or else.  That's the repeal.  Not a total repeal, but good start.

What about replacement?  The crux of the House plan is a refundable tax credit ranging from $2,000 to $4,000 a year – less for younger individuals, more for older people who by virtue of their age must pay more for insurance.

Young invincible millennials, in good health and not engaging in risky activities, may choose to play the odds.  They can bank their tax credit and pay out of pocket for the occasional trip to the doctor without inviting the attention of the IRS and associated penalties.

The tax credits could be used by lower-income individuals and families to purchase insurance they might have lost due to the scaled back Medicaid expansion.  Insurance products should become more competitive if, as promised by President Trump, they become available across state lines and without requirements that individuals purchase insurance they don't want or need.

A popular provision maintained in the House bill is protection for those with pre-existing conditions who might otherwise be denied coverage – at least if they maintain continuous coverage without letting their policy lapse.

It's a good start – but what are the pitfalls?

Fewer people will be covered.  But that is the tradeoff for not being forced to buy insurance.  Tax credits to purchase private insurance will mitigate much of the lost coverage.  The Medicaid expansion repeal won't kick in until 2020, giving people several years to explore other insurance options.

If fewer are covered, this will also be turned against Republicans, painting them as uncaring, cruel, mean-spirited, and the usual other epithets.

The tax credit will be considered another new entitlement and many fiscally conservative congressmen and senators will balk at this, perhaps even voting against it.  A day after the announcement, conservative political groups like Heritage Action, Freedom Works, and Club for Growth are lining up to criticize the bill.

Remember: this is only the House bill.  The Senate will have their own version, perhaps very different from the House bill.  Physician and senator Rand Paul has his own plan, which may not easily reconcile with the House bill.  Both houses of Congress need to agree on and pass a final bill before it makes it to the president to be signed into law.

What if Senate majority leader Mitch McConnell forces an immediate vote on the House bill in the Senate, before thoughtful review and analysis?  Remember when Democrats forced through Obamacare that way?  How did that work out?

What might the Senate do?  If enough GOP senators defect and vote no, the bill dies.  This would be the appropriate ending for a lousy bill.  Suppose Senate Democrats get mischievous.  Recognizing that it's a bad bill, what if a handful of Democrats vote to pass it, saddling the Republicans with Obamacare version 2.0, then beating them over the head with it during the 2018 midterm elections?

There are also the numbers and myriad other details.  The Congressional Budget Office needs to score the bill.  What if it costs as much as Obamacare and insures fewer individuals and families?  Some replacement.  From bad to worse.  The left will have a heyday with that.

Republicans don't want a repeat of Nancy Pelosi's "you have to pass the bill to find out what's in it."  Obamacare was one of the primary reasons Democrats lost 1,200 elected seats in the past eight years.  If the GOP rushes through and passes a bad bill, it could suffer a similar fate.

Most likely, Democrats will oppose it just because.  Given how unhinged Democrats have become over anything and everything Trump, I suspect they would even oppose Bernie Sanders's plan, a complete government takeover of health care, if it were proposed by President Trump.  Expect grandstanding by Democrats.  The evening news will feature stories of the chronically ill losing their medical care and Granny being pushed off a cliff by Paul Ryan.  Hollywood will be active in its opposition, with TV medical shows highlighting people dying due to the Republican health care plan.

Then there is President Trump.  Will he sign a bad bill that doesn't reconcile with his campaign promises?  Thus far, Trump has been doing exactly what he promised.  Health care reform is unlikely to be an exception.

I won't join in the chorus of immediately throwing cold water on the House bill.  This is but a first step on a long promised journey to repeal and replace a flawed and floundering mess called Obamacare.  If the legislative process plays out as it is supposed to (not holding my breath), with Senate and presidential input, the final bill may be very different from and far better than the House bill released this week.  Stay tuned for the next chapter.

Brian C Joondeph, M.D., MPS, is a Denver-based physician and writer.  Follow him on Facebook  and Twitter.

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