“Skinny” repeal isn’t skinny at all

Republican senators are expected to vote later today on a plan that many journalists have dubbed “skinny repeal.”

Skinny repeal refers to a bill that would roll back the Affordable Care Act’s requirement to purchase health insurance, as well as a few more minor provisions.

I’ve used the term skinny repeal in my own reporting. But I’ve come to think it’s wrong, and I’m going to stop.

Here’s why: Skinny repeal isn’t really that skinny at all. Rolling back the individual mandate would cause an estimated 15 million to 16 million Americans to lose coverage, according to Congressional Budget Office analyses of that policy. The nonpartisan office expects that premiums would rise 20 percent in the individual market.

The individual mandate is a crucial part of the Affordable Care Act’s expansion of coverage. It is meant to induce those with low medical costs to sign up for a plan anyway or else face a $695 fine. This helps make a market that accepts all patients — including those with expensive medical conditions — function with reasonable premiums.

Health care nerds like to talk about the Affordable Care Act as a “three-legged stool.”

One leg is the expansion of coverage to all Americans, including those with costly preexisting conditions. That requires the second leg: the requirement that everybody purchase coverage so the market doesn’t get swamped with the sickest enrollees.

The third leg is subsidies — if the government is going to require all Americans to purchase coverage, after all, it needs to make sure that product is affordable.

Repealing the individual mandate chops off a leg from that stool. You would not call your new two-legged stool a “skinny stool.” It would be a broken stool that does not work.

The same should be true for a bill that repeals the individual mandate. Insurance plans expect the market to become dysfunctional if healthier Americans were to lose the incentive to sign up. “A system that allows people to purchase coverage only when they need it drives up costs for everyone,” the Blue Cross Blue Shield Association wrote in a statement Wednesday.

And let’s be clear: Republican senators absolutely understand this. We know this because in 2012, 27 of them signed on to an amicus brief arguing in favor of the Supreme Court striking down the individual mandate.

“The individual mandate is at the heart of the PPACA, and the remainder of the statute necessarily depends on its inclusion because without the mandate, the statute’s reforms cannot work as intended,” the group wrote. “Indeed, the proponents of the PPACA knew at the time Congress considered the legislation that without the mandate both the number of uninsured and the price of premiums would skyrocket.”

This brief was signed by Senate Majority Leader Mitch McConnell (R-KY), Senate Finance Chair Orrin Hatch (R-UT), and more than a dozen others (hat tip to Abbe Gluck at Yale University, who flagged this brief’s existence to me).

Repealing the individual mandate is only skinny when you compare it to other Republican bills, like the House-passed American Health Care Act, which would cause an estimated 23 million to lose coverage. But the world of the AHCA isn’t the world we live in. The world we live in is one in which the Affordable Care Act is law, and that is the appropriate baseline for thinking about any health bills floating around Capitol Hill.

Skinny repeal is, simply put, a misnomer. This is a bill that would cause millions of Americans to lose coverage, individual market premiums to rise, and the size of that market to shrink. There is nothing skinny about that.