Senate version of health care bill goes from worse to bad

The Obamacare replacement that the House sent to the Senate might as well have had a note scrawled across its pages: Save us from ourselves.

And the Senate bill does indeed improve upon the House bill in several important ways. But is that enough to make the new version an electoral winner for Republicans? Probably not.

The best argument for the bill is twofold. First, it officially reconciles the Republican Party to the idea that the government should provide support for working-class health insurance. Second, it takes part of Obamacare’s basic structure — tax credits, pegged to income, to enable the lower-middle class and near poor to afford coverage — and uses it to further higher-deductible plans (which tend to reduce health-care cost inflation) rather than comprehensive ones (which exacerbate it) and subsidies for private insurance rather than Medicaid for the near-poor, because private coverage may deliver better health.

Also reasonable: a loosening of age-based price controls to make the exchanges more viable, and that the Senate’s bill’s income-based credits are less stingy than the House bill’s flat credit, and thus less likely to leave the poor and old with impossible premiums to pay.

But stinginess is still the essential problem for the Senate’s alternative. High-deductible insurance plans make less sense the poorer you get.

The bill’s attempted transition from Medicaid to private coverage would inevitably leave the people who are transitioning worse off, with deductibles that they couldn’t pay even if their choice of doctors were technically better.

Meanwhile, the middleclass Americans most justifiably aggrieved by Obamacare — the people just above the subsidy cutoff, buying unsubsidized insurance that Obamacare made less affordable — will gain little from the bill, and because the subsidy ceiling is lowered (from 400 percent of poverty to 350 percent) their ranks will actually increase.

The House bill, flawed in so many respects, at least made an effort on this front, since its flat subsidy was available to the people currently getting hosed by Obamacare prices. But maintaining a smaller version of that subsidy would have cost money, so instead the health care law’s biggest losers will continue to lose out.

Politically, then, it’s hard to see a clear constituency for this bill, apart from the mostly wealthy voters, who will appreciate its rollback of Obamacare’s tax increases. Because it preserves more reasonable subsidies than the House bill and because its Medicaid drawdown happens in the distant 2020s — which is to say, perhaps never — it might not be an outright political catastrophe.

The Republican Party could pass this bill, flaws and all, and then use the projected cost savings for a tax reform that’s actually organized around payroll tax cuts, refundable child-tax credits, a larger earned-income tax credit and other measures that would make up for the thinning of working-class insurance coverage with more cash in paychecks and bank accounts.

If that happens, I will recant my opposition to this bill.

But I don’t expect any such recantation to be required, because the Republican Party remains what it is, not what the country needs it to become.