Okay, so the highly flawed GOP Obamacare replacement bill has passed the House of Representatives. But as it stands now, it has virtually no chance to get a 51 vote majority in the Senate.
And we know why: The real threat that many Americans will lose their health insurance coverage due to the bill makes it a dead letter to every Democrat and several Republicans in the upper chamber. The "lost coverage" line, especially for people with pre-existing conditions, is already the dominant narrative in the news media, and that's a narrative no member of Congress will be able to ignore.
There are many other problems with this bill from both a liberal and conservative perspective. It simply does not fix the growing problems with Obamacare and actually makes them worse by increasing its fiscal liabilities. But as any politically savvy observer can tell you, this deal ain't over. We know the bill is set for a good deal of changes before the Senate even sets a vote date.
If the Trump administration really wants to get this done, it should focus on these three changes:
1) Give us a real solution to the pre-existing trap.
The loudest Democratic criticism of the bill, and the thing that has clearly frightened Republicans the most, is the threat of people with pre-existing health conditions losing their insurance coverage. The amended bill that just passed the House provided more money to cover those Americans, but almost no one thinks that added funding will be enough. A key fact that everyone needs to understand is that Obamacare did not give these people health care, it guaranteed them coverage at the same premium costs as everyone else. That has never been a workable or even sane policy. People who use a service more than others need to pay more for those services, period. If they are too poor to do so, they should be on Medicaid. If they're too old and are retired, they should be on Medicare. For the people who weren't covered by those two programs, Obamacare went too far and put too much cost on everyone else paying for their insurance. It would have been much better to mandate some kind of rule that forbids insurers from charging ruinous premiums for those customers, (say no more than twice the average), but holding them to unrealistic "one size fits all" premium charges is a big reason why so many insurers have exited the Obamacare exchanges over the past 2 years.
Another problem is that this bill still doesn't do anything to stop people from waiting to buy insurance until they get sick or injured. It's one thing to forbid insurers from rescinding coverage or jacking up prices on existing customers once they do get sick, but forcing them to take all comers at the same premium prices even when they wait to buy coverage until the last minute isn't realistic either. The bill must be changed to allow insurers to penalize people who do this with higher premiums of some kind, or the system will be gamed by everyone smart enough to figure this out.
2) Ditch the waivers to give people real insurance choices.
One of the biggest reasons why Obamacare hasn't encouraged more insurers to compete for our business is because of the heavy minimum requirements the ACA forced into every plan before it could be sold to the public. The GOP bill does not eliminate these so-called "essential benefits" and instead allows individual states to apply for waivers to approve health plans that do not include them. This is a waste of time and won't serve the public well. Americans who want to buy bare-boned insurance plans should be allowed to do so under any circumstances. If the Senate adds that provision to this bill, smaller insurers will be able to get into more markets and bigger insurers will have a new incentive to provide more choices. More is more.
3) Ditch the Medicaid expansion and provide the truly poor with more.
What is the moral mission of government? Is it to get as many people onto some kind of pittance of a welfare program, or is it to provide the truly poor with high quality aid? It's time this question be asked and answered with an increase in Medicaid benefits and quality and a reversal of the cynically political process of just patronizing as many potential voters as possible. Amending this bill to provide a significant amount of services and money for people at and below the poverty line would make the measure much more politically sound and morally correct.
Oh, and there's one more thing. These three changes could easily make a number of GOP holdouts vote for the bill, and maybe put a few moderate Democrats like Senators Joe Manchin and Heidi Heitkamp into the "yes" column too. But there's actually something the White House and the Republicans in Congress need to do first: Craft a better message. The GOP hasn't ever been very good at communicating with the American public when it comes to making the argument for free market ideals. With almost every news anchor and late night show hosts like Jimmy Kimmel to compete with, the Republicans as they are now haven't got a chance to get this bill passed amendments or no amendments.
Someone in the GOP, starting with President Donald Trump, has got to start making a more emotionally powerful and sympathetic case for this or any other health insurance bill they're backing. Until that happens, the senators who are gun-shy about this entire process will never feel confident enough to vote for the bill in any form.
Even though the above list is short, it's far from easy. Basically, this will take a major effort in public and behind the scenes from the Republicans and the White House if they want to move this effort forward. And they need to get to work right now.
Commentary by Jake Novak, CNBC.com senior columnist. Follow him on Twitter @jakejakeny.
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