"Democrats, of course, have been solidly against Republican efforts to unravel Obamacare from the beginning. But some conservatives are joining them in arguing that the health care bill passed by the House last month contains some poorly written policy that could leave more Americans uninsured than would be under the ACA, or potential alternatives. Senate Republicans are writing their own measure, but considering that the House bill is something of a blueprint, these critiques could be a sign that some conservative health policy analysts will end up at odds with conservative politicians on reform efforts. Specifically, some conservative critics want the Senate to take a different approach than the House did on one of the toughest health policy issues: how to get insurance to people who are too poor to pay for it.
Republicans have long wanted to curb the cost of Medicaid, the state and federally funded public health insurance program for the poor. Since at least 1981, regular efforts have been made to rein in the program by changing it from an entitlement, where the federal government pays a set portion of the bills no matter how many people are enrolled, to a per capita cap or block grant. Those changes would give states a limited amount of money and more control over how to spend it than they have in the current arrangement. The House GOP bill would accomplish that longtime goal while also rolling back the Affordable Care Act’s Medicaid expansion, which made everyone earning under 138 percent of the federal poverty line (about $16,600 for an individual) eligible for the program.1 The House GOP bill would freeze enrollment in the expanded program starting in 2020.
But the bill, the American Health Care Act, would cut Medicaid without adding much in the way of support for people to buy insurance. Joseph Antos and James Capretta — longtime Obamacare critics and health policy scholars at the conservative think tank the American Enterprise Institute — have criticized that part of the proposal, writing that too many low-income families would be unable to afford insurance.
Republicans often argue that income-based entitlement programs such as Medicaid discourage people from working or taking better jobs, because earning more can mean losing the government benefit.2 But in the case of the House GOP bill, argued Avik Roy, a conservative writer and health policy expert, older, working-age adults could lose coverage if they earn too much to qualify for Medicaid. That’s because the House bill provides subsidies to buy insurance based on age, not income and the cost of insurance, as is currently the case with the ACA. And lower-income, older adults will be getting a lot less in subsidies than they currently get, even though their subsidies are higher than for younger adults. According to estimates from the Kaiser Family Foundation, a low-income 60-year-old who earned slightly too much to be eligible for Medicaid would likely be on the hook for thousands of dollars a year in premiums, and in some cases, the cost could be more than her total income."