Senate Republicans could well be on the brink of very significant market-based health care reforms not seen in a generation - and simultaneously on the precipice of blowing it.
On Thursday, Senate Republicans unveiled their latest version of replacing Obamacare and this time, it included a version of an amendment by Sen. Ted Cruz (R-Texas) that says if an insurer sells at least one plan in-state that complies with federal regulations, then it can offer other lower-cost plans. Senate Majority Leader Mitch McConnell (R-Ky.) and Cruz are to be praised for having it included in this latest offering.
This differs from the original Cruz Amendment, which allows insurers that sell at least one insurance plan that complies with federal regulations to sell any other kind of plan that consumers demand - finally bringing down the costs of premiums. The Senate plan is almost there, but can it get across the finish line?
Either way, what is on the table would for the first time in a long time bring down the cost of premiums for the American people, and truly help to make insurance more affordable. It stands as an improvement upon the House legislation that passed last month.
The plan also keeps a provision from the House plan allowing states to opt out of the federal regulations completely.
Yet, Senate Republicans are without a vote to spare on their bid to keep the campaign promise they have been making in elections going back to 2010 - despite having voted to put similar legislation on former President Barack Obama's desk in 2015 to be vetoed.
If that was good enough for Obama to veto - legislation that did not even touch the regulations driving up the cost of premiums - then why is this legislation which opens up the market for non-regulated plans not good enough for President Donald Trump to sign?
All of this calls into question, once again, Republican rhetoric in elections versus policies that are offered up. Although imperfect, these reforms would leave the health care system in a better place than it currently finds itself with changes that respect the states and individual choice in insurance markets.
The individual and employer mandates are gone. Medicaid expansion is phased out, freeing up resources for states to focus that program's spending, for example, for seniors who require long-term care either in nursing homes or with home attendants. After all, who should be prioritized for Medicaid? Working age adults with jobs via Medicaid expansion? Or the set percentage of seniors without a penny to their name with debilitating illnesses like dementia?
Ending Medicaid expansion is the compassionate choice, but it is also one that helps open up the market for lower-cost plans via the Cruz Amendment. This will make it easier for individuals who were using Medicaid expansion to now afford a private health insurance plan. Lower premiums are the key to that reform. Without it, the enterprise of passing a health care bill would almost be worthless.
On inclusion of the provisions in the legislation, Sen. Cruz stated, "I am encouraged that the revised bill ensures consumers have the freedom to choose among more affordable plans that are tailored to their individual healthcare needs, and expands health savings accounts so that consumers can pay health insurance premiums on a pre-tax basis."
Cruz suggested more could be done, adding, "This is a critical step in the right direction and I will continue to work closely with my colleagues to unite our conference around a bill that can pass, and that honors our promises and that truly lowers premiums, which is crucial to providing relief from Obamacare."
However, the statement goes on to suggest that "the Senate's bill should allow consumers to buy and issuers to sell health insurance free from Obamacare's insurance regulations, but subject to state law, while providing consumers with the choice to buy plans subject to Obamacare's insurance regulations, including preexisting conditions, with subsidies and other assistance."
Meaning, with so few votes to spare, this latest revision may not be the final offering from Senate Republicans. A few more compromises may be necessary - there is still much more that could be done to improve the bill - but conservatives would do well to note that moving in the direction of the original Cruz Amendment into the legislation to improve it is no small accomplishment.
Opening up insurance markets for lower-cost plans is a game-changer. It is one of the most significant reforms to the U.S. health care system in a generation, allowing insurers to provide plans that the American people actually want - instead of those that the government said they had to have.
Robert Romano is the Vice President of Public Policy of Americans for Limited Government.