Rand Paul’s health care demands, explained

This is the web version of VoxCare, a daily newsletter from Vox on the latest twists and turns in America’s health care debate. Like what you’re reading? Sign up to get VoxCare in your inbox here.

Defector of the Day: Sen. Rand Paul

Each day leading up to the Senate vote, we’ll take a closer look at a Republican senator who seems to be on the fence on the Better Care Reconciliation Act, what they want, and what role they’re likely to play in the debate. Today we focus on Kentucky’s most famous ophthalmologist, none other than Sen. Rand Paul.

Mark Wilson/Getty News Images

Sen. Paul has made it clear he is no fan of the Senate health care bill. He has constantly criticized it for keeping too much of the Affordable Care Act intact. Today, though, he issued a clear list of demands:

  • Expand the role of association health plans. As I reported this weekend, there is a little-noticed provision in the Senate bill that would allow small businesses to purchase skimpier health plans with fewer benefit mandates. Paul wants individuals to be able to buy into those health plans, too. Under his proposal, individuals would be able to join up with small businesses to form an association for purchasing coverage. They would have more bargaining power as a large group and be able to demand low premiums if the individuals and small-business employees involved were young and healthy. But this could be a raw deal for sicker Americans, who may not be able to join up with these associations and would face higher premiums as a result.
  • Kill off the law’s short-term stability fund for Obamacare. Paul doesn’t like the funding being put toward keeping the health law running in 2018 and 2019, before the Senate bill would transition to the new system. This includes the funding of cost-sharing reduction subsidies for low-income ACA enrollees.
  • End the premium tax credits — or at least don’t make them advanceable and refundable. Right now, the ACA tax credits are paid on a monthly basis (rather than a lump sum as part of an annual tax refund) and go well beyond offsetting the taxes that Americans owe the government. Paul doesn’t like that much at all. He doesn’t like how this builds a new entitlement program, and would like to see these tax credits become non-advanceable and nonrefundable. This would have the practical effect of putting coverage financially out of reach of many who rely on this part of the law.
  • Get rid of the waiting period. The Senate leadership on Monday added a six-month waiting period for those who want to join the individual market and have had a lapse in coverage at some point in the past year. “This continues the top-down approach that has led to increased premiums and has not changed behavior of the young and healthy who are priced out of the market, and those who game the system to purchase insurance after they become sick,” Paul writes.

What will get him on board: Some version of these demands, probably. It’s instructive to look at how the Freedom Caucus negotiations worked. That group started with a long list of demands but ultimately whittled down the list to two nonnegotiable proposals. So it’s possible we’ll see Paul settle for a few of these ideas rather than his entire list.