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Honorable Mark Sanford

Representing the 1st District of South Carolina

Vote Notes: H.R. 244 Consolidated Appropriations Act, 2017

May 2, 2017
Blog Post

Congress voted last week to extend government funding for seven days, and it looks like tomorrow there will be another vote on a funding bill. This one will take us through the end of the federal government’s financial year, which is September 30. With this dealt with, it seems that there has been a refocusing on the healthcare debate, and that vote may well come up on Thursday.


Accordingly, I’d like to dig into the latest iterations of where things stand on the healthcare debate and my views on it.


The issue has picked up again with the acceptance of Congressman Tom MacArthur’s amendment to the so-called “manager’s amendment” of the American Health Care Act.

To start, I continue to be impressed and struck by the intensity of people’s heartfelt feelings and beliefs on this vital subject. In many ways, there is nothing more personal than one’s healthcare. People have gone out of the way to tell their stories and to point to children or loved ones who have been helped very directly by the Affordable Care Act. On the opposite side of the equation, I’ve heard from any number of small business people who are struggling to pay the rising premiums in the individual healthcare marketplace. Over the course of my eight town hall meetings, I have overwhelmingly heard from people who believe in either a single-payer system or maintaining the Affordable Care Act in its present form.


The difficulty I find in maintaining the status quo is that it is unsustainable. Premiums cannot continue to go up by 30%, as they did last year in our state. In the same vein, people really don’t have insurance if their deductible is well beyond their means to pay for it. Finally, when choices continue to constrict, one ultimately sees availability affected as well. We are down to but one provider in South Carolina.


So, we really are between a rock and a hard place in this debate.

On the one hand, you want to be attentive to the many who’ve come out and made their case for leaving their benefits alone. On the other, you want to be attentive to people who increasingly can’t pay for the limited insurance that they do have that often comes as a consequence of a deductible so high that insurance is effectively non-insurance, given people’s inability to afford it.


It’s for these reasons that in the first round of this debate I staked out a “no” position. I am one of only three Republicans who actually voted no on the bill. I did this as it came through the Budget Committee and then subsequently whipped no on the bill that was to have come up weeks ago. These efforts combined with the position of others led to the bill being pulled...and consequent great criticism, and even threats in some circles and praise in others.


As we’ve gone through this debate, I have learned a lot and have come to believe that we ought to, in a more transparent form, help those in need who draw a bad genetic card or find themselves dealing with the consequences of a horrendous accident. Concurrently, given that I believe in the marketplace, I have also come to believe that you should let insurance really act as insurance for the vast majority in the individual marketplace who find themselves without the tragedy of a horrific accident or a bad fate with regard to illness.


The individual marketplace makes up about 7% of our total healthcare market in the U.S. The Affordable Care Act covers about one-half of this population - 3.8% of the healthcare marketplace to be exact. Most people are served in group insurance. Medicare covers those above the age of 65. TriCare covers those in active duty. The VA covers veterans, while Medicaid has historically helped women and children of limited financial means.

The vexing question in this debate revolves around how we as a society do three things concurrently: 1) lower premiums (insurance must be affordable to be available), 2) maintain a patient’s right to have choice (on the most difficult of personal decisions, who wants a government or insurance bureaucrat to decide whether to turn off the life monitor for a grandparent in life’s last hours?), and 3) protect those who draw a bad genetic card through no fault of their own (we aren’t a third world country that leaves people to die on the side of the road...people with no insurance and no ability to pay for coverage are admitted to emergency rooms based on federal law - but the rest of us pay for them).


I believe the bill Senator Rand Paul and I offered solved these problems of cost, access, and choice...but it is not the bill we might see on Thursday.


But some of what I have struggled with is still tied to what the Senator and I were trying to get to: how might we induce more people to get insurance? And how does that coverage hold when one has indeed been dealt a bad and expensive condition in life? The Affordable Care Act was well intended and attempted penalty as its way of getting more young people to join the insurance ranks. Instead, millions of young and healthy people believed it was in their best interest to pay the penalty and not enroll. This meant the Affordable Care Act may have been well intended...but it was also financially unsustainable.


The MacArthur Amendment is not a cure-all, but I do think it strengthens the bill enough in protecting those with pre-existing conditions that if it came to the floor in original form, and were combined with an amendment to prevent Congress from exempting itself from the bill, I would vote yes. This would simply advance the debate to the Senate where I think the bill's prospects are even tougher than they were in the House.


Here is my take on that amendment and what it might mean.


In attempting to strike some sort of balance between protecting those in need and letting insurance be insurance for those without the bad genetic card, it would allow for the Founding Fathers’ belief in a federalist answer to divine these fairly unnavigable waters. Think about that for a second. The Founding Fathers began our country when it consisted of only about 4 million people. That’s smaller than the state of South Carolina. I was once governor here, and we live in a state where if you don’t know everyone, you know of somebody who can get you to the person that you don’t know. Yet with a population this small, the Founders built federalism in a big way into their belief on the proper balance of government. As our population has increased to the tune of hundreds of millions of people, this idea of federalism becomes that much more important. Washington might indeed know what’s best for a population as small as 4 million, it will never know what’s best in a population that includes the diversity that comes with hundreds of millions.


This at the core is what the MacArthur Amendment employs. It says if Vermont wants to have a single-payer system and the costs that are associated with that, it can choose to do so. Concurrently, if South Carolina wants to have a more market-based system, they can do that as well. We can literally have a competition of ideas and see which ones work best.

The amendment didn’t stop there though. States would only be freed of things like community ratings, essential health benefits, and age banding if they set up a risk pool modeled after Maine’s successful program. What does this mean? One, no one could be denied coverage for a pre-existing condition based on guaranteed issue which is built into the bill. Two, no one could be charged more for health insurance based on a pre-existing condition as long as they indeed stayed enrolled in insurance.


For folks that disregarded even this requirement of continuous coverage, they too would be protected. For their state to have exempted itself from the community ratings, which could drive prices higher for someone with a pre-existing condition, the state would have had to set up a risk pool. Not just any risk pool, because some states set up disastrous risk pools under the Affordable Care Act, but one initially modeled after Maine’s. Theirs required a cross-pollinating fee from the healthy to those who ended up sick. It was nominal, perhaps $4-5 a month, but helped to pay the cost of those less fortunate. These pools, at the federal level for the first three years and then subsequently at the state level, would serve as a final backstop in making certain that no one with a pre-existing condition was financially crowded out of coverage. There has been $30 billion allocated in this bill toward these pools.


I think this equation represented a win for those most concerned about the maintenance of our social safety net, while from a conservative standpoint, there were wins in the revised bill with the elimination of certain Affordable Care Act taxes coming a year earlier, work requirements, and the federalism model that made possible things like the Maine-style risk pools.


In this regard, the bill represents a tweaking of the Affordable Care Act. It does not eliminate it. It is not full repeal. It was at that point that a number of us stood in front of the Capitol and said we didn’t see it that way. We saw it as nothing more than a starting point. In many ways, it still is. All this means that parties on both sides of this debate don’t like it, and I think that’s generally a good indicator of a compromise bill. Though I would like to see much more in the way of change, it’s arguably the most we can get through the House at this point. It’s come a long way from what Speaker Ryan defined as a binary choice just a few months ago when he said it was this or nothing. That we had to take it or leave it.


As one of the holdouts on this bill, I have tried to look for ways of being something other than just “no” and to be constructively engaged in the debate. I also had to ask whether or not there was enough in the newest version of the bill to warrant advancing it to the Senate for further debate. In this case, I believe there is, which is why I’m staking out the position that I have.

If the bill as I know it now changes, or if the provision for congressional exemption are not to be removed...then my thinking on this vote would change accordingly. But until that happens, I wanted to let you know my latest thinking on both the amendment and the bill at large.