NEW YORK (MainStreet) The problem with reforming the Patient Protection and Affordable Care Act, also known as Obamacare, is that there is not yet a consensus that the program should survive.
Repeal efforts continue.
As National Journal columnist Ron Brownstein recently wrote, "Congress can't wield a scalpel while Republicans are still clamoring for the guillotine."
What might a scalpel look like?
One thing that might go with a scalpel, writes Joe Deaux at TheStreet, is the employer mandate, the requirement that employers with more than 50 employees buy health insurance for their workers.
Employers buy health insurance, because they're deductible expenses but not counted as salary. If your salary is $50,000 and your employer pays $10,000 a year for your health insurance, in other words, they have $60,000 in expenses, lowering the profit they pay taxes on, while you pay taxes on just $50,000 the $10,000 in health insurance isn't counted in your income.
Edward Kleinbard of the University of Southern California, former chief of staff for Congress's Joint Committee on Taxation, estimates the tax cost of this policy at $250 billion per year. That's 6.5% of 2014's $3.8 trillion federal budget more than we're spending on housing, education, and the environment combined.
So if employers want to forego this tax benefit, the reasoning goes, let them. The subsidies in the ACA are designed to replace the tax benefits for workers who buy their own health insurance.
The employer mandate has already been put off twice. It starts next year for employers with 100 employees, and a year later for those with 50 or more. The penalty for failure to comply is also modest, just $2,000 for each employee after the first 30.
As a result, Republicans who don't want to count employees working 30-40 hours per week as full-time are getting some support from Democrats. http://thehill.com/blogs/healthwatch/health-reform-implementation/202636-delays-cast-doubt-on-o-care-mandate Why make employers take subsidies they obviously don't want?
Giving employees the subsidies their bosses were getting to buy health insurance is one compromise. What about lowering the cost of insurance more directly?
Sen. Mark Warner of Virginia has offered the Expanded Consumer Choice Act to do just that.
It creates a "copper plan," paying only 50% of health care costs, reducing insurance premiums by 20%. Current "bronze" plans pay 60% of costs, silver plans pay 70%. The copper plans would enjoy the same subsidies as other plans those with incomes of up to 263% of the poverty line would get subsidies.
Warner would also raise the employer mandate to 100 employees, meaning 98% of employers would no longer have to buy health insurance.
Switching responsibility for getting health care coverage from employers to employees, with subsidies equivalent to those employers now enjoy, would also make the current "Hobby Lobby" case moot. An employer's religious objections to contraception won't matter if they're not paying for the insurance.
Warner says he's not done. He wants state insurance commissioners to find ways insurers can offer plans across state boundaries. He wants to ease the reporting requirements for employers. He has already gotten catastrophic plans approved for those people who have their old plans cancelled because they don't comply with the Obamacare law.
None of these proposals stand a chance of passing until those now devoted only to repealing Obamacare stand down. If you want to get rid of something you're going to do all you can to make it look like a mess. You're going to use any mess as evidence for repeal. You're not going to clean up the mess that would only aid your political opponents.
The 2014 election, like the 2012 election, thus shapes up as another referendum on Obamacare. If you don't like it vote Republican, if you like it vote Democratic. If Republicans can win the next two election cycles, if they can elect a President and Congress to their liking, Obamacare will likely be repealed in its entirety.
But if, as in the past, you get a muddy result, anything like the status quo, Obamacare reform might yet get its chance.
--Written by Dana Blankenhorn for MainStreet