Paul Ryan, Donald Trump, and Mike Pence have a new plan. Shockingly, it involves making life harder for the sick. Photo: Alex Wong/Getty Images

Earlier on Wednesday, the Republican health-care plan appeared all but doomed heading into Thursday night’s scheduled House vote. But a last-minute alteration has dramatically revived its prospects. Republican leaders are reportedly planning to add to the bill provisions to strip away essential health benefit requirements for insurance. This move would placate many, perhaps all, of the most arch-conservative opponents of the bill, making it far more likely to assemble a majority. It would also probably make the bill radioactive in the Senate by making the insurance system even more punitive and unaffordable to Americans with serious medical needs.

The proposal is to eliminate ten essential benefits that, according to the Affordable Care Act, must be offered as part of any insurance plan. Those benefits are:

• Outpatient care without a hospital admission, known as ambulatory patient services

• Emergency services

• Hospitalization

• Pregnancy, maternity, and newborn care

• Mental health and substance use disorder services, including counseling and psychotherapy

• Prescription drugs

• Rehabilitative and habilitative services and devices, which help people with injuries and disabilities to recover

• Laboratory services

• Preventive care, wellness services, and chronic disease management

• Pediatric services, including oral and vision care for children

Conservatives loathe these benefits, because they impair the pure free-market function of the insurance system. In their ideal world, people could buy any kind of insurance they want. The most frequent complaint about essential health benefits is that it forces men to pay for maternity care. (Literally, this is the best example they can identify of a frivolous benefit Obamacare forces insurers to sell people.) Allowing people to customize their insurance allows them to buy cheaper plans covering only the kinds of medical treatments they want. Eliminating these regulations would make Trumpcare acceptable to the far right and probably, though not certainly, enable its passage through the House.

This maneuver has mechanical and substantive problems. Mechanically, there’s a reason the House never included this provision before: They believed Senate rules prevent it. The Republican plan, remember, is not to pass health care as a normal bill, but to pass it as a budget reconciliation bill. This gives them the ability to evade a filibuster in the Senate, but it also means that bills can only include budgetary measures. A repeal of regulations on health insurance are not a budgetary measure. Republican sources tell Politico, “When Republicans wrote the blueprint for the repeal bill in 2015, the parliamentarian made clear that insurance regulations would not comply and the issue wasn’t put under significant scrutiny.”

Today, some Republicans suddenly changed their minds. Senator Mike Lee, one of the three Senate Republicans opposed to Trumpcare on the grounds that it is too left-wing, relayed a conversation with the Senate parliamentarian, who would be tasked with making this decision. According to Lee’s report, relayed through Philip Klein, the parliamentarian told Lee repealing such regulations might be eligible for a reconciliation bill.

There is no way to tell if Lee is summarizing the parliamentarian accurately. Regardless, Republicans seem to believe it. They don’t have a lot to lose: Since their bill was almost dead anyway, having it die in the Senate would hardly be any worse. Indeed, it would be better for at least some House members to pin the blame on Senate rules rather than to have Obamacare repeal die in their own chamber.

The substantive issues are more critical. Eliminating essential health benefits does not lower the cost of health coverage, it redistributes it. If men, or women past childbearing age, no longer share the cost of childbirth in their insurance premiums, then the cost of insurance for somebody who might have a baby would become wildly expensive. Healthy people can save on costs by buying plans that don’t cover all sorts of chronic diseases, but then people who do have those conditions would be stuck paying for their own treatment.

A system without essential benefits would make the law’s protections for people with preexisting conditions meaningless. Insurers couldn’t turn you away if you had a pricy condition, but the only people who wanted to buy plans covering them would be sick and expensive, making covering their conditions unaffordable — just like before Obamacare existed. Eliminating these reforms would enable young, healthy people to enjoy lower premiums, as long as they remained young and healthy. It would essentially jack up the massive redistribution from the old and sick to the young and healthy already in Trumpcare to new heights.



It is possible that House Republicans can rush this enormous change through, passing their bill quickly without hearings or an analysis by the Congressional Budget Office. It is also conceivable this version of the bill could actual survive Senate rules and evade a filibuster. But it makes passage through the Senate even less likely than it already is. The Senate has a large Republican bloc concerned about the fiscal and humanitarian effects of throwing millions of people off their insurance. The new version of Trumpcare reportedly taking shape would be even more Darwinian, more disruptive and politically painful than the old one.