Is an Obamacare solution already staring Congress in the face?

Sen. Susan Collins was “disappointed” – decorous Senate speak for really, really unhappy. 

The Mainer is arguably the most moderate Republican in the Senate, a reliable bridge-builder across the partisan divide. She came to the floor on Monday to introduce a compromise bill co-sponsored with Sen. Bill Cassidy, a Republican doctor from Louisiana, to replace the Affordable Care Act.

But Democrats panned the bill before it got out of the starting gate – even while observers say it could point the way out of the political wilderness over what to do about Obamacare.

The compromise is unique to Republican legislation in that it allows states that want to keep Obamacare to do so. Other states could choose a more flexible approach that lets them drop the much-maligned mandate that requires individuals to purchase health insurance or pay a fine. 

Minority leader Charles Schumer (D) of New York described the bill as an “empty façade” that would create “chaos” not care.

To Senator Collins, Senator Schumer’s response was disappointing for reasons beyond her bill – and speaks to Washington’s challenge going forward. At a time when both parties appear to be playing by hyperpartisan rules – oppose anything from the other side first, ask questions later – the space for people trying to find solutions is minuscule.

Her expectation was not that her bill would be accepted in full down to the last comma and ampersand. But negotiations have to start somewhere, and if every bill from the other side is summarily rejected, then the next few months – or years – will amount to very little.

“I guess what disappoints me most,” Collins said, “is that the Democratic leader’s response really represents what’s wrong with Washington, D.C.”

“If we are going to have a leader on the other side of the aisle denounce to the press and come to the Senate floor to criticize a bill … that has not even been introduced yet, where are we?” she added.

Politically appealing

The Cassidy-Collins bill is important because of the political dynamics around Obamacare.

Republicans can unite around repealing Obamacare, but they have not been able to coalesce around a plan to replace it. Democrats are doing everything they can to thwart and blame Republicans.

While Republicans can use a budgetary maneuver to easily repeal the guts of the ACA, at some point, replacement legislation is going to have to go through the Senate, where most legislation has to clear a 60-vote threshold to pass. That will necessarily involve Democratic buy-in given the GOP’s slim 52-to-48 majority.

That’s where Senators Cassidy and Collins come in.

“If you can say to a blue-state senator who’s really invested in supporting Obamacare, ‘You can keep Obamacare, but why force it upon us?’ we think that helps us get to 60,” Cassidy told reporters on Monday.

Such a “state-choice” strategy could work politically, says Cynthia Cox, an expert on the law’s insurance marketplaces at the Kaiser Family Foundation. “States that really have embraced the ACA, especially California, have shown it can work.”

On the other hand, she says, states that have not embraced the law’s benefits, such as expanding Medicaid to cover more poor people, “may want to take one of these alternative paths the proposal offers.”

In describing their bill, the Patient Freedom Act, Cassidy told reporters that allowing states to decide what they want follows a “Republican principle” and will help his colleagues accept an Obamacare option for states that want it.

The bill’s key alternative option for states would do away with individual and employer mandates and benefit requirements, and instead auto-enroll everyone who isn’t covered by employer or public healthcare in a basic package.

That package would include individual, federally funded health savings accounts, a high-deductible health plan, and a basic pharmacy benefit. People could opt out of the plan, or purchase more insurance. This alternative would enlarge the pool of covered customers, the bill’s authors explain, theoretically covering all of a state's uninsured population.

It would keep the popular parts of the Affordable Care Act, including no life-time caps on care, no prohibition of pre-existing conditions, and allowing young adults to stay on their parents’ insurance.

And it would reportedly be paid for with the taxes and Medicare savings that now fund the Affordable Care Act. States would also receive funding for the current law’s Medicaid expansion – even if they do not expand Medicaid.

That funding sounds “fairly generous,” says Ms. Cox. But it’s also another reason why budget-hawk Republicans would oppose the plan.

Voices of opposition

Indeed, Rep. Mark Meadows of North Carolina, the leader of the hard-right Freedom Caucus, has come out against the bill, saying Obamacare needs to go entirely.

Democrats, meanwhile, won’t like the uneven standards for Americans, with consumers in ACA states having a higher level of benefits than those in non-ACA states.

“You could be setting up a situation where you have individuals in similar situations, but in different states, who might receive different healthcare insurance coverage,” says G. William Hoagland, senior vice president at the Bipartisan Policy Center.

Still, he says he sees the bill as “a good step forward,” adding that “Susan Collins’s involvement on this, particularly, is important, from a bipartisan perspective.”

Schumer’s rejection of the bill should not be taken as a final no, suggests Lawrence Jacobs, a political scientist at the Humphrey School of Public Affairs at the University of Minnesota.

“I think Schumer was saying ‘We’re not a cheap date,’ ” Professor Jacobs says. The minority leader’s only leverage is to keep Republicans anxious that repeal and replace will take a long time, or won’t happen at all, he explains.

It’s unclear what strategy Republicans will eventually settle on, but Jacobs says the Cassidy-Collins bill could become the “basis of negotiation and creativity.” It has something for Democrats. It has something for Republicans. Both parties have to give up something.

“Collins may not have the last say,” according to Jacobs, “but she’s had a very important first say.”