Tuesday, April 18, 2017

Tom Cotton's Obamacare repeal dance

Posted By on Tue, Apr 18, 2017 at 12:26 PM

click to enlarge COTTON: "My position is that every Arkansan should have access to affordable, quality care. No exceptions, no excuses." - BRIAN CHILSON
  • Brian Chilson
  • COTTON: "My position is that every Arkansan should have access to affordable, quality care. No exceptions, no excuses."

Amidst the fireworks at yesterday's town hall hosted by Sen. Tom Cotton and U.S. Rep. French Hill, I thought the most interesting exchange came when Cotton was asked about the consequences of repealing the Affordable Care Act.

Neither the questioner nor Cotton ever utter the words "Medicaid expansion," but Cotton's response appears to signal that — although he remains committed to "repealing and replacing" Obamacare — he is politically uncomfortable in practice with eliminating the coverage expansion that has provided health insurance to hundreds of thousands of Arkansans.

A citizen from Little Rock asked Cotton, "Do you support repealing the Affordable Care Act so that 300,000 Arkansas citizens will lose their health care?"

A key piece of context here: 300,000 is the approximate number of Arkansans currently covered by the Medicaid expansion (in Arkansas, that's via a unique program known as the private option, or "Arkansas Works," which uses Medicaid funds to purchase private health insurance for low-income Arkansans). This is a question that Cotton dodged constantly during the 2014 campaign: Cotton says he supports repealing Obamacare — but won't that mean kicking Arkansans off of the private option, which relies on Obamacare funding? Cotton bobbed, weaved, and refused to answer when he ran for the senate.

Cotton is still avoiding specifics and relying on vague promises and wiggle words, but crucially, his answer yesterday implied that any repeal-and-replace effort should protect those 300,000 Arkansas. Indeed, he said, he opposed the recent repeal-and-replace bill proposed in the House because it failed to do just that. Here's Cotton:

I would disagree with the premise of your question, that if we repeal the ACA [300,000 Arkansas citizens will lose their health care]. Part of my problem with the bill that was introduced in Congress last month, though, is it would have that result. It was moving too fast, I didn't think it got it right.
Again, some context: The American Health Care Act (AHCA), the Republican House plan to repeal and replace Obamacare that died last month, would have enacted a de facto end to the Medicaid expansion. The bill would not have immediately kicked current beneficiaries off of coverage, but in practice, it would have phased out the coverage expansion in a state like Arkansas (see here for the nuts and bolts of how the AHCA would have killed the Medicaid expansion). In Arkansas, the governor's "Arkansas Works" program would soon be dead. This is why some red-state governors in expansion states were wary of the bill. It sounds like Cotton was wary for the same reason — part of his problem with the bill, he says, "is it would have that result."

The Freedom Caucus objection to the AHCA was that it didn't go far enough in completely repealing Obamacare. But the problem with the bill Cotton articulates here is that it would do exactly what the questioner was worried about — threaten coverage that hundreds of thousands of Arkansans rely on. Again, he doesn't come out and say it, but when we're talking about "300,000 Arkansans," we're talking about the Medicaid expansion population. Cotton doesn't say what his answer is, but his response presupposes that the expansion population should continue to have health insurance in some fashion, or at least get more protections going forward than were offered in a bill like the AHCA.

Here's the rest of Cotton's response:

I do support repealing Obamacare.

There's no doubt — I have no doubt that some Arkansans have benefited from Obamacare. I bet some of you are here today. There were a lot of problems with our health care system before Obamacare. It was too expensive, people with pre-exisiting conditions couldn't get coverage, there were caps on what your coverage could get that were often buried in the fine print. So I have no doubt that some Arkansans benefited from Obamacare. Many more were hurt by Obamacare, though, in the form of higher premiums, higher deductibles, higher co-pays, loss of access to the doctor of their choice. In my opinion, we can get help to those people who need it without hurting so many people. That's the approach I'm going to take. 
This is mostly vague talking points, but note that Cotton's allegations about Obamacare are very specifically targeted toward certain aspects of the ACA exchanges (the regulated marketplaces where consumers who don't get health insurance through a job or a public program like Medicare can purchase individual plans). He offers no critique of the Medicaid expansion. The entire premise of his response is that he wants to enact changes to the health care law without harming those 300,000 Arkansans he was asked about.

Later, Cotton was asked about Trump's promise that whatever replaced Obamacare would "cover everyone." Cotton's response:

This is one reason I didn't support the bill [the AHCA] that was originally proposed. My position is that every Arkansan should have access to affordable, quality care. No exceptions, no excuses.
That's a commitment, presumably, that includes the population reliant upon the state's Medicaid expansion for coverage under current law.

There are a whole mess of caveats here: Cotton in the past has voted multiple times for bills that repeal the Medicaid expansion altogether or repeal the entire ACA and replace it with nothing; he has recently stated that "Medicaid is a welfare program...not designed for able-bodied adults"; if some version of the Medicaid expansion does continue, he would surely like to see aggressive conservative alterations, such as work requirements, changes to eligibility, and enforceable premiums (changes the governor is already pursuing); the phrase "access to affordable, quality care" leaves plenty of political wiggle room over what counts as access, what counts as affordable, and what counts as quality; he offered no specifics about just what sort of plan he actually would support and what it would entail for those 300,000 Arkansans; he offered no firm guarantee that whatever he has in mind would actually maintain coverage for all those folks; and Cotton supports changes to the Medicaid program itself that would severely decrease funding available to states. He made no detailed line-in-the-sand promise about current beneficiaries or about the "Arkansas Works" program itself.

All of that said, it is striking that Cotton said that one of his core objections to the AHCA was that it threatened the future of health insurance for 300,000 Arkansans — that it didn't do enough to "cover everyone." Now that Obamacare repeal is an actual possibility instead of a campaign promise, Cotton is coming face to face with a harsh political reality: "Arkansas Works," the Medicaid expansion program that provides health insurance to around a tenth of the state's citizens — a signature policy of the state's Republican governor — is reliant on Obamacare funding. Cotton's comments strongly suggest (at least, if we are to try to make coherent sense of them) that at this point, for him, an acceptable Obamacare replacement plan cannot simply abandon the Medicaid expansion population.

Cotton is walking a fine political line but it sounds like the political calculation has been made: He doesn't want to vote for a new bill that will allow town hall questioners to say he's snatched health insurance away from 300,000 Arkansans.

Perhaps a question for the Clinton School interview tomorrow: Does Cotton promise that any Obamacare replacement he votes for will still offer health care coverage for the expansion population? Details, please. 

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