WASHINGTON – One could say that Republican U.S. Sen. Johnny Isakson kept close tabs on the House's tumultuous effort to repeal and replace the Affordable Care Act this spring.
In fact, Georgia's senior senator followed much of the initial debate in real time from his hospital bed as he recovered from a pair of surgeries on his lower spine.
“Involuntary,” Isakson deadpanned as he recounted the hours spent watching cable news coverage of the legislation. “Under the influence of narcotics, by the way.”
It took the House GOP two months to get its Obamacare replacement bill, known as the American Health Care Act, over to the Senate, where the legislation now faces an uncertain future.
With the Democrats unwilling to touch any legislation that could unwind former President Barack Obama’s signature policy achievement, Republicans are left to pass a health care alternative on their own.
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Majority Leader Mitch McConnell has an incredibly delicate task ahead as he seeks to unite his divided caucus behind a new proposal. The Kentucky Republican must find a plan that assuages both conservatives who want minimal government intervention in the health care system and moderates concerned about constituents losing coverage, with only two votes to spare.
Georgia’s senators aren’t considered big holdouts in this particular debate -- Isakson is known among GOP leaders as a team player and U.S. Sen. David Perdue has positioned himself as a key ally of President Donald Trump and his agenda. Their support, however, is crucial to the survival of any GOP plan.
In interviews late last week, both Perdue and Isakson expressed their desires to quickly replace Obamacare and flexibility regarding how exactly to do that.
Among their top priorities is making sure that the 19 states that didn’t expand Medicaid under Obamacare, including Georgia, don’t get financially disadvantaged under such legislation.
“I want to get something that works for the people who need it and that we maintain the independence for the states in terms of taking care of their own people,” Perdue said.
Both want to work with Democrats but indicated they weren't sure whether any proposal could win their colleagues' support, much less that of the 50 other Republicans.
Isakson, who had earlier backed a separate GOP health care plan that would let states decide whether to keep Obamacare or pursue something different, repeatedly emphasized that he did not want to commit himself to specific policy proposals at the expense of a final deal.
"You’ve got to consider everything in the totality of the proposal," he said.
Here is where the two stand on some of the health care debate’s biggest fault lines:
Medicaid payments
As our colleague Misty Williams reported earlier this month, the House GOP’s bill fundamentally changes the way the feds pay states for Medicaid, the federal health care program for the poor. The federal government has for years paid states a certain percentage of all of their Medicaid costs. The measure passed by the House instead would allow states to opt for “block grants,” which would pay states lump sums based on a predetermined formula.
Perdue said he’s worried that a state with a growing population such as Georgia could end up locked into an outdated formula that could limit the stream of federal dollars. “We’re a growth state,” he said. “I’d prefer to have a per capita relationship in terms of how they manage that money out every year.” Isakson expressed similar concerns.
Medicaid expansion
Georgia was one of 19 Republican-led states that chose not to expand Medicaid under the Affordable Care Act. (State leaders argued it was too costly.) The House GOP’s bill would bar new enrollment under Obamacare's Medicaid expansion on Dec. 31, 2019 for the states that expanded.
Both Isakson and Perdue echoed Gov. Nathan Deal, who has argued that any Republican health care plan must not "punish" Georgia and other states that haven't expanded Medicaid. Boiling it down, they don't want the Peach State to end up with fewer federal resources than expansion states in the long run. "Most of this stuff is 'show me the money,'" Isakson said. "It's all about cost, it's all about compensation." Perdue said that if a Senate bill sets aside a pot of funding for non-expansion states such as Georgia, he wants the governors to have the flexibility to send money to priorities such as ailing rural hospitals.
Tax credits
The House’s health care plan would provide tax credits to help people pay for insurance based on age, not income as Obamacare does. As Williams breaks down, the GOP plan would also give wealthier Americans tax breaks.
Perdue said he does not think "anybody making $200,000 needs a tax credit to pay for their health insurance" and that both age and income should be determining factors. Isakson previously supported a GOP proposal that would means test the House GOP's age-based tax credits. In other words, it aims to redistribute the benefits toward lower-income people by phasing out the credits for wealthier individuals.
Preexisting conditions
One of the Affordable Care Act’s most popular provisions bars insurers from denying people coverage if they have preexisting medical conditions. President Trump and congressional Republicans have promised to keep that intact. It's currently unclear how the final version of the bill passed by the House would impact this pledge. As PolitiFact reports, “much would depend on unknown policy decisions by individual states – and then how those decisions are implemented.”
Isakson said there is “an obligation to provide a way for those who are uninsured or uninsurable to be able to be insured and insurable.” He also said he is not opposed to including incentives or eligibility requirements for wellness and disease management because of their ability to lower health care costs down the road. Perdue said there are ways of taking care of people with preexisting conditions without making the cost of care “explode” but did not elaborate.
Underlying principles
Perdue: "What I'm hoping is that we don't make the same mistakes that Democrats made (with Obamacare), and that is trying to force a political solution on this thing. I don't care what the terminology is, whether it's repeal and replace. Whatever it is, I want to get something that works for the people who need it and that we maintain the independence for the states in terms of taking care of their own people."
Isakson: "I want to be a part of a solution, but I want it to be one that works. I don't want it to be one where the government is kind of driving everything down."
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