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Congress is in over its head on AHCA

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Maybe congressional aides are busy having great behind-the-scenes discussions about improving or replacing the Affordable Care Act commercial health insurance rules.

But I think the logical conclusion from watching three House committees mark up the American Health Care Act proposal is this: Most elected officials are in way over their heads when they try to talk about this stuff.

Many of the Democrats spend their time complaining about Republican meanies taking care away from the poor, and many Republicans obsess about side issues, such as work requirements for able-bodied adults who want Medicaid, because they have no idea how health insurance worked in 2009, no idea how the ACA changed the health insurance business, and no idea what the AHCA proposal would do, other than that it would change something to do with taxes.

Related: Three Republicans reject AHCA at House Budget markup

The House Energy & Commerce Committee and House Ways & Means Committee started by marking up the bill during grueling sessions March 8.

The House Budget Committee marked up the bill Thursday.

I have many things to do and couldn’t watch as much of the video as I would have liked. But I watched a fair amount live, and more of the recorded versions. I also sifted through the videos using the video transcript search tool on C-SPAN.

There were some highlights.

Rep. Diane Black, R-Tenn., chairman of the House Budget Committee seemed genuinely nice and bipartisan, for example, thanked the Democrats, and the staff members on both sides, at the end of her committee’s markup.

But the Democrats on the committee seemed to focus mainly on general complaints about how terrible AHCA would be for poor people and how good it would be for rich people. The Republicans tended to focus on ways to direct Medicaid toward more deserving poor people. 

At the Ways & Means Committee, Rep. Ron Kind, D-Ind., and Rep. Vern Buchanan, R-Fla., engaged in a few minutes of conversations that suggested that they both had given some thought to the existence of commercial health insurance.

Kind, for example, knew that the ACA tax credit for small businesses is too complicated. He knew that Medicare is trying to shift away from paying for care on a fee-for-service basis.

Buchanan, responding to Kind, pointed out that he’s talked to the chief executive officer at Blue Cross and Blue Shield of Florida and heard that Florida Blue has had problems with the ACA. In other words: Buchanan understands that companies actually have something to do with health insurance. Health insurance doesn’t just spawn in cornfields when you spread enough of the right tax credits on them.

At the Energy & Commerce Committee, Rep. Scott Peters, D-Calif., talked about an AHCA tax credit analysis performed by Blue Shield of California.

Republicans occasionally mentioned the loss of Blue Cross and Blue Shields when talking about the problems of their states’ ACA public exchanges.

But terms such as “actuary,” “claim,” “antiselection” and “risk pool” did not seem to come up very often.

The committee members did not seem to be especially conscious of the problem of setting up individual health plans for 2018, for sale on or off the exchange, and that the window for making the 2018 individual market happen, or even for setting up some kind of temporary replacement program, is closing now.

Some people think the federal government should be more actively involved in running the U.S. health care finance system. Some people want to reduce federal involvement.

One acute problem with congressional involvement in the current commercial health insurance system is that the level of congressional health insurance literacy seems absurdly low.

Here’s a modest proposal: If Congress stays involved with commercial health insurance, someone should add a provision to the next must-pass budget bill that requires 20 members of the House and Senate to become active members of the National Conference of Insurance Legislators and 20 to become active members of the National Association of Insurance Commissioners. For extra credit: require all 40 of those lawmakers to attend the annual meetings of America’s Health Insurance Plans (and, to be egalitarian: the annual meetings of the American Hospital Association, the National Association of Health Underwriters, the America Council of Life Insurers, and the Consumer Federation of America).

Even without considering the ACA, Congress is really the board of a life insurance, health insurance and retirement annuity company with a significant security operation and a few side investments in the arts, space exploration and park land. Members of Congress should get the background they need to have intelligent conversations about those operations.


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