For seven years now, the mantra “repeal Obamacare” has been both a spasm of revanchist rage and a cynical ploy to keep a segment of the electorate motivated to vote for Republicans. It was also frequently deployed in the belief that the GOP would not be unexpectedly thrust into a position where their voters could expect them to make good on the promise.
But Donald Trump’s Republican Congress convened only three days ago, and members are already finding that eliminating Obamacare will be far messier, politically, than devising and implementing it was for Democrats.
As Republicans hurry to repeal the law, “they’re not even close to agreement about what comes next — or even when the repeal should take effect,” Politico reported late Wednesday. “Republicans are reckoning with the reality that dismantling a nearly seven-year-old law that reshaped a $3 trillion health sector and covers millions of Americans is more daunting than simply campaigning against it.”
Republicans got themselves into this mess at least in part because of a broad, conservative failure to treat Obamacare on its true terms rather than as an evil abstraction conjured by a political foe. In an important sense, there is no Obamacare anymore; there’s just the health care system Republicans are inheriting, and the one they will leave behind.
The Affordable Care Act was designed to fill a huge national health coverage gap in a minimally disruptive, integrated way. It was not designed to be a modular component that could be inserted and removed at will.
When Democrats controlled the government in 2009, they could have theoretically passed legislation that opened an existing public insurance system like Medicare or Medicaid to working-age people. But that would have unspooled existing insurance markets, creating significant disruption for consumers and relentless opposition from carriers and other powerful interests.
Democrats instead struck bargains with stakeholders across the health industry, which created political and economic space for a major coverage expansion but left most existing arrangements untouched. They subjected insurers to more regulation, but guaranteed them millions of new customers; they cut reimbursement rates to hospitals, but with the understanding that a spike in insured patients would help them recoup lost revenues. Most of those patients were expected to be poor people who would be added to state Medicaid rolls, in an expansion paid for almost entirely by the federal government.
The political downsides to this approach were fairly obvious at the time, and have become more clear as the law’s been implemented. It’s complex and inequitable; it doesn’t cover everyone; it turns people into customers in an amoral and unpopular market, rather than into users of a simple public utility. But the upside was that it could be slowly blended into the existing fabric of the health system without rending the whole thing and starting over. It’s not a single patch in a strange patchwork. Removing the stitching won’t just re-create a hole, but leave the rest of the quilt more tattered than it was before.
Eliminating a program that covers 20 million people will create a backlash on obvious humanitarian grounds, but that’s far from the only challenge Republicans now face. Repealing the Medicaid expansion will confront hospitals with an uncompensated care crisis; repealing private insurance subsidies will collapse the individual marketplaces; repealing the coverage guarantee will allow insurers to again discriminate against sick people. Delaying these repeal measures with no promise that they will be replaced with an alternative that makes providers and patients whole, will create major disruptions in the health care system anyhow. This is a stickier wicket than many strident Republicans in Washington realized, and the ones who did know were cynical enough to over-promise anyhow.
Republicans thus find themselves at odds not only with one another, but with health industry stake holders and their supporters, too.
The American Medical Association (a powerful doctors association), and the even more powerful hospital lobby have warned Republicans not to repeal Obamacare unless an alternative is enacted in tandem. When GOP repeal plans are described to them, Trump-supporting Obamacare beneficiaries in key swing states are rightly horrified. This week, Trump adviser Kellyanne Conway told CNBC, “we don’t want anyone who currently has insurance to not have insurance,” but according to Politico, “Republicans are now realizing how hard it will be to replace the law, and many of them have plainly settled on the fact that they will never be able to craft a plan to insure as many people as Obamacare does.”
In 2013, Obamacare precipitated the cancellation of a small number of individual market insurance policies, and the political consequences were immediate and severe. Under the GOP’s vision, the number of cancellations will climb into the millions, and leave no alternatives for those who lose their plans to opt into. Under Obamacare, hospitals, insurers, and other providers overhauled their business models, but in a deliberate and productive way. If Republicans do what they’re promising, rural hospitals are likely to be driven out of business abruptly. And then there’s the fact that many people will die.
Republicans must now choose between walking onto what they acknowledge is a political minefield and reneging on the political promise that has defined them—that became their organizing principle as an opposition party—during the Obama years. In a more sane environment, they would accept Democrats’ offer to improve Obamacare in ways that Trump voters say they want, and then claim victory in the repeal fight.
A Kaiser Foundation study of these voters, as described in a New York Times op-ed by its president and CEO, Drew Altman, found that “[t]hose with marketplace insurance ... saw Medicaid as a much better deal than their insurance,” and that “Trump voters on Medicaid were much more satisfied with their coverage.” Offering Medicaid to the uninsured would make the system more truly universal than it is today. It would approximate a more prototypically conservative model of insurance in which the government guarantees all people can get treatment in the event of major illness or accident, but draws the line at financing more routine care. It would win Democratic buy-in, be more popular than Obamacare, and Trump and the GOP could claim credit for ending the health care wars.
Naturally, such a remedy is under consideration by nobody.