Trump’s promise to promote health insurance sales across state lines? Not in the American Health Care Act. Mr. Price’s commitment to loosen burdensome benefit rules for private health plans in Obamacare? Also not in the bill. Mr. Ryan’s favored policy of high-risk pools? Not there either. The goal of giving states more flexibility to run their Medicaid programs according to local conditions? Barely.
There is some debate among Senate experts about exactly what sorts of insurance regulations will be allowed in a bill passed through the special budget procedure. Such bills, which cannot be filibustered and thus can pass with only 50 Senate votes (along with Vice President Mike Pence’s tiebreaking vote), must adhere to the so-called Byrd rule.
Named after Robert Byrd of West Virginia, who was the longest-serving senator in history, the rule says that senators can stop a bill under this special procedure if it contains matter “extraneous” to the federal budget. There are many complex details, which is why there is uncertainty about what counts. The House staffers who wrote the American Health Care Act apparently felt that changing Obamacare’s requirement that all plans cover 10 basic categories of benefits would break the rule. (But, for example, they believed that changing the rules for how much insurance companies could charge older customers was O.K.)
Alone, the American Health Care Act’s effects don’t match particularly well with favorite Republican talking points about health reform. As I wrote this week, the bill doesn’t do much to lower insurance premiums or to improve competition in insurance markets. It doesn’t allow customers to choose a customized health plan that is “right for them,” though it would allow insurers to sell products with slightly higher deductibles.
That’s why Republicans need the other prongs.
Those prongs will not necessarily be easy to, let’s say, thrust into action. Though there is some latitude for the Department of Health and Human Services to change regulations under Obamacare, not everything on the G.O.P. wish list can be achieved through executive action alone. The minimum benefit package, which critics say makes insurance more expensive than it should be, is clearly specified in Obamacare.
So is the requirement that insurers offer plans at the same prices to healthy and sick customers alike, a major impediment to creating high-risk pools that would cover sick customers. Mr. Price and his staff can make some changes on the margins. And a longstanding Medicaid waiver program can allow some customizing of state programs, but only through a detailed application and approval process. Major structural changes will take legislation.
On the legislative side, Republicans are hemmed in by their narrow Senate majority. Democrats have so far taken a hard line against Republican efforts to dismantle Obamacare, and that means that any health care bill not passed through the special budget procedure will take 60 votes in the Senate to overcome a filibuster.
That means such bills will need every Republican to vote for them, plus the votes of eight Democratic senators. It seems hard to imagine that eight Democrats would want to vote for a law that strips away all Medicaid requirements for states in favor of maximum flexibility. That means that Prong 3 may be the hardest to achieve, unless Republicans are willing to tear up the filibuster or Byrd rule, changes that could have wide-reaching implications.
And what of the “prong” metaphor itself? It’s hard to know what Republicans may be picturing as they evoke the three-prong strategy. But people’s suggestions on Twitter include an electrical plug, a trident and a pronghorn.