She saved Obamacare. Now she’s poised to destroy it.

Tax or health care reform?

Sen. Lisa Murkowski (R-AK) and other lawmakers, head to the Senate on Capitol Hill in Washington, July 13, 2017. (CREDIT: AP Photo/J. Scott Applewhite)
Sen. Lisa Murkowski (R-AK) and other lawmakers, head to the Senate on Capitol Hill in Washington, July 13, 2017. (CREDIT: AP Photo/J. Scott Applewhite)

Senator Lisa Murkowski (R-AK) casted a pivotal vote over the summer, where she — along with Sens. Susan Collins (R-ME) and John McCain (R-AZ) — saved the Affordable Care Act (ACA) from being repealed. She didn’t just vote against repeal once; she voted against three different G.O.P. health bills and shot down another in September.

But on Tuesday, she said she supports legislation that most health experts say will undermine the current health law. In an op-ed in the Daily News-Miner, Murkowski said she supports Republican tax legislation that repeals the individual mandate, an ACA provision that requires people to have insurance or pay a tax penalty ($695 or 2.5 percent of income, whichever is more).

“I believe that the federal government should not force anyone to buy something they do not wish to buy in order to avoid being taxed,” wrote Murkowski. “That is the fundamental reason why I opposed the Affordable Care Act from its inception.” Repealing the individual mandate provides relief to those penalized for not purchasing unaffordable insurance, she added.

Collins said this past Sunday she doesn’t think repealing the individual mandate should be in the tax bill. McCain, who said he was against the repeal process and not the policy during the last go-around, has largely been quiet about whether he supports the idea. White House officials said during Sunday shows over the weekend that the tax bill does not need to include a mandate repeal. But with Murkowski’s op-ed, the White House and Congress look like they are inching closer to the votes needed to pass tax legislation.

Murkowski makes a valid point throughout her op-ed: plans on and off the ACA marketplace can be expensive without federal assistance (like tax credits for premiums or cost sharing reductions for out-of-pocket costs). ThinkProgress recently spoke with one Maryland resident who said the same thing about his state’s health plans.

But while the point is largely true, the proposed solution — repealing the mandate — doesn’t help people. Marketplace insurance will become more expensive without the mandate. People who purchase their own insurance without federal aid may receive some tax cuts from the G.O.P. tax bill, but higher premiums offset gains and make people financially worse off, according to a new Commonwealth Fund study. Older adults with moderate incomes are worse off. The unsubsidized crowd will be forced to go without insurance or — once the president’s executive order on the ACA is implemented — purchase skimpier, unregulated health plans.

What about those who receive federal subsidies — the very people the ACA has helped according to Murkowski? While they may be immune to an estimated 10 percent increase in premiums after a mandate repeal, enrollees cannot avoid the insurance companies’ reaction to the news. The American Academy of Actuaries, a 19,000+ member group that includes retired actuaries and academicians, said in a letter to Congressional leaders on Tuesday that “insurers would likely reconsider their future participation in the market.”

A repeal of the mandate could once again lead to counties without any insurer option next open enrollment — a risk avoided this open enrollment period. Alaska has just one insurer, but this news could also be disastrous for other states who are holding on to two or three insurers.

Repealing the individual mandate may sound harmless, but as the Kaiser Family Foundation’s Larry Levitt said on Twitter: “it’s the mechanism that allows guaranteed coverage for pre-existing conditions.”

The three-legged stool, a metaphor often used to describe how an insurance marketplace works, explains why the individual mandate is so necessary:

  1. The first leg: Insurance companies are required by law to provide health plans to anyone who pays for it — no matter the person’s medical history.
  2. Second leg: To ensure the marketplace isn’t exclusively made up of sick people — which can be very expensive for insurers — put in place a penalty to incentivize people to purchase care.
  3. Third leg: Include financial assistance to make insurance more affordable for enrollees.

Every leg is important; every group in this arrangement — insurance companies, federal government, and patients — needs to do its part. This is why without the mandate, the Congressional Budget Office estimates 13 million will be without insurance by 2027.

It’s tempting for Murkowski to support a tax bill that repeals the individual mandate because it also opens up Alaska’s Arctic National Wildlife Refuge for oil and gas drilling. As advocates put it, Murkowski is essentially choosing drilling over the environment, ecosystems in the region, and now health care.

It’s true that the ACA isn’t perfect. Many are going without insurance and paying the penalty under the individual mandate. Millions of people remain uninsured, and nearly half of the uninsured population said in 2016 that it was because insurance costs were too high.

But insurance keeps people healthy, and prevents future financial catastrophe. There are better ways to help the people Murkowski refers to in her op-ed.

One of the policies health experts are suggesting is reinsurance. Reinsurance — or insurance for insurance companies — can help make coverage more affordable for people without federal assistance. Alaska set up a reinsurance program, which dropped premiums sharply for 2018. The state used to have the highest premiums nationwide (a point Murkowski glosses over in her op-ed), but it no longer does; now it has the fourth highest. It’s still pretty expensive — which might have something to do with the state only having one insurer.

Another option is to provide federal assistance directly to consumers. A group of Democrats introduced legislation over the summer that would eliminate the cliff that prevents people from purchasing subsidized insurance. “A 60-year-old making $47,521 per year—one dollar more than the limit—has to pay more than $900 per month in premium costs for a standard plan in some areas of California,” wrote Senator Dianne Feinstein (D-CA). “That’s simply not affordable. Our bill would fix this problem.”