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“A Political Disaster Of Unimaginable Proportions”: Why Republicans Wouldn’t Actually Repeal Obamacare

Last week, in a bold example of their governing prowess, congressional Republicans took their 62nd vote to repeal the Affordable Care Act, and this time they actually passed it through both houses and sent it to President Obama to be vetoed. Naturally, they were exultant at their triumph. Speaker Paul Ryan admitted that there is as yet no replacement for the ACA, but they’ll be getting around to putting one together before you know it. The fact that they’ve been promising that replacement for more than five years now might make you a bit skeptical.

What we know for sure is this: If a Republican wins the White House this November, he’ll make repeal of the ACA one of his first priorities, whether there’s a replacement ready or not. To listen to them talk, the only division between the candidates is whether they’ll do it on their first day in the Oval Office, in their first hour, or in the limo on the way back from the inauguration.

But I’ve got news for you: They aren’t going to do it, at least not in the way they’re promising. Because it would be an absolute catastrophe.

Let’s take a brief tour around the consequences of repealing the ACA. First, everyone who benefited from the expansion of Medicaid would immediately lose their health coverage. According to Charles Gaba of acasignups.net, who has been tracking these data as assiduously as anyone, that amounts to about nine million people. Granted, the working poor are not a group whose fate keeps too many Republicans up at night, but tossing nine million of them off their health coverage is at least bound to generate some uncomfortable headlines.

Then there’s all the people who now get their health coverage through the exchanges that the ACA set up. Remember how fake-outraged Republicans were back in the fall of 2013 because some people with crappy health plans got letters from their insurers telling them that they’d have to sign up for a plan that was compatible with the ACA’s new standards? The truth was that some of them would wind up paying more for coverage while others would pay less, but it was the subject of a thousand credulous news stories portraying them all as victims, to Republicans’ unending joy.

Now imagine that ten million people, the number signed up for private coverage through the exchanges, all had their coverage simultaneously thrown into doubt. Think that might cause some bad press for the party and the president who did it?

There’s more. The ACA also allowed young people to stay on their parents’ insurance until age 26; three million took advantage of the provision. They’d likely lose their insurance too. Oh, and if you’re a senior on Medicare? Get ready for the return of the “doughnut hole” in prescription drug coverage, which the ACA closed.

Let’s add in one more element (though there are lots of the ACA’s provisions we don’t have time to discuss). One of the central and most popular provisions of the ACA banned insurance companies from even asking about pre-existing conditions when they offer you a plan. About half of Americans have some kind of condition that in the old days would mean they either could get insurance but it wouldn’t cover that condition, or they couldn’t get covered at all. If you bought insurance in the old days, you remember what a hassle it was to document for the insurer every time you saw a doctor for years prior. You don’t have to do that now, but if Republicans succeed, we’ll be back to those bad old days. So they can look forward to lots of news stories about cancer survivors who now can’t get insurance anymore, thanks to the GOP.

But wait, they’ll say, our phantom replacement plan has a solution: high-risk pools! This is a common element of the various inchoate health-care plans Republicans have come up with. Anyone who knows anything about insurance knows why these are no solution at all. They take all the sickest people and put them together in one pool, which of course means that the premiums to insure them become incredibly high. As I’ve written elsewhere, high-risk pools are the health insurance equivalent of going to a loan shark: You might do it if you’re desperate and have no other option, but you’re going to pay through the nose. So good luck with that.

Even if Republicans could come together around a single replacement plan, that plan would still be a political disaster. The theory behind their health-care ideas is that once we inject some more market magic into health care, everything will be great. But there are a couple of important things to understand about this idea. First of all, their plans don’t even try to achieve anything like universal coverage. It just isn’t one of their goals, and as a consequence, implementing their plans is going to mean a lot more uninsured than we have now, a reversal of the progress the ACA is made, with millions or even tens of millions of people likely to lose coverage. Second, even if the market mechanisms they use were to work out how they predict—and it’s almost certain they won’t, but let’s give them the benefit of the doubt for a moment—it would take a substantial amount of time.

In this, the ACA is direct. You can’t afford coverage? Here’s a subsidy, now you can afford coverage. But under Republican plans, more people shopping around for their health care is, over time, supposed to bring costs down, which will eventually translate to lower premiums. But in the meantime, while we wait for the invisible hand to perform its alchemy, millions upon millions of Americans will get screwed. Think there’s going to be a political backlash?

I suspect that many conservatives understand that, but still think that in the long term, their small-government ideas will leave us with a superior system. But that still leaves them with a political dilemma. On one hand, repealing the ACA would be spectacularly disruptive—in fact, unwinding the law will probably be more disruptive than putting it in place was, now that the entire health-care and health-insurance industries have adapted to it—and there will be millions of people victimized by repeal. It will be a political disaster of unimaginable proportions.

On the other hand, they’ve invested so much emotional, political, and rhetorical energy over the last six years into their opposition to this law that they would seemingly have no choice but to repeal it, no matter the consequences. Liberals may argue that the ACA would have been a lot better if it hadn’t worked so hard to accommodate the market-based character of the American health-care system, but Republicans have been telling their constituents that it’s the most horrific case of government oppression since the Cultural Revolution (or as Ben Carson says, “the worst thing that’s happened to this nation since slavery”). They can’t exactly turn around to the people who elected them and say, “Look, I know we said we’d repeal this thing, but that’s going to be a real mess. How about if we just make some changes to it so it works more like we’d like?”

Or maybe they could. Just look what happened to Matt Bevin, the new governor of Kentucky. He ran on a platform of purging the state of every molecule of that despicable Obamacare, but now that he’s in office, things are looking a little more complicated. That’s because Kentucky is one of the great ACA success stories, where the expansion of Medicaid brought health insurance to a half a million low-income people who didn’t have it, and the state’s health-care exchange, Kynect, was a model of success. So Bevin is now backtracking on his promise, saying that instead of just eliminating the Medicaid expansion he’s going to reform it. And Kynect may get the axe (which would mean just turning it over to the federal government), but that won’t happen for quite some time, if at all.

And that’s what I think we’d see if we actually got a Republican president and a Republican Congress forced to deal with the consequences of what they’ve been promising for so long. Once they have the ability to bring down such a health-care calamity on the public, it’s not going to seem like such a great idea. They’ll say they’re as committed to it as ever, while behind the scenes they’ll be frantically trying to figure out how to do something they can call “repeal” but that won’t actually get rid of all the things people like about the law. I wouldn’t be surprised if we saw a “repeal” bill that, in the name of an effective transition, left much of the law in place, then slowly instituted their market-driven ideas over time. Because there are limits to even what kind of damage an all-Republican government would inflict—if not on the country, then at least on their political fortunes.

 

By: Paul Waldman, Senior Writer, The American Prospect, January 10, 2016

January 14, 2016 Posted by | Affordable Care Act, Obamacare, Republicans | , , , , , , , , | 2 Comments

“The Equivalent Of Thinking The Iraq War Would Be A Cakewalk”: Why The GOP Presidential Candidates Can’t Reform Health Care

In the last few days, Scott Walker and Marco Rubio released health care plans, and other Republican candidates are sure to follow soon. Most will probably be pretty similar, even if some are more fully fleshed out than others.

But they’ll all share one feature, the thing that tells you that they aren’t even remotely serious about this issue: they will take as their starting point that the entire Affordable Care Act should be repealed.

I say that that shows they aren’t serious not because I think the ACA has done a great deal of good, though I do think that. I say it because it shows that they’re completely unwilling to grapple with both the health care system as it exists today, and how incredibly disruptive the wholesale changes they’re proposing would be. Walker’s plan even says, “unlike the disruption caused by ObamaCare, my plan would allow for a smooth, easy transition into a better health care system.” This is the health care equivalent of thinking the Iraq War would be a cakewalk.

The reality is that repealing the ACA now that it has been implemented would mean a complete and utter transformation of American health care. Republicans have often lamented that the law was so terribly long and included many different rules and regulations — yet now they act as though the law amounts to just a couple of rules here and there that can therefore be tossed out without too much trouble. But they were right the first time: the law is indeed complex, and has brought hundreds of changes big and small to American health care, not just in how people get insurance but in how Medicare and Medicaid work, how doctors and hospitals are paid, and in all sorts of other areas.

The ACA established health care exchanges. It brought millions of people into Medicaid, it closed the Medicare prescription drug “doughnut hole.” It gave subsidies to small businesses. It funded pilot projects to explore new means of providing and paying for care, it imposed new regulations on insurance companies. It created new wellness and preventive care programs, it provided new funding for community health centers. It did all that, and much more. You can argue that each one of these was a good or a bad idea, but you can’t pretend that unwinding them all would be anything resembling a “smooth, easy transition.”

We know why every Republican health care plan has to start with repealing the ACA: politics. Republicans have spent the last five years telling their constituents that they’re going to repeal it any day now, and they’ve held over 50 repeal votes in Congress. They’ve refused to admit that a word of it has any merit, even as they try to incorporate some of its more popular reforms (like protections for people with pre-existing conditions) into their own plans. So they’ve backed themselves into a corner where whatever any Republican offers has to start with repeal.

Which is why all their plans, the ones that have been released and the ones yet to come, are absurdly unrealistic. They pretend that it will be no problem to completely transform the American health care system — and there will be no losers in such a transformation, only winners — which shows that they have no intention of actually doing so. In fact, I’d go so far as to say that if a Republican gets elected next November, he’ll be relieved when his health care plan dies in Congress.

Let’s contrast that with how Democrats acted in 2008, when there was a vigorous debate in the presidential primary over health care. The three leading candidates, Barack Obama, Hillary Clinton, and John Edwards, all had very similar plans, similar because they reflected the Democratic consensus on health care reform that had evolved in the decade and a half since Bill Clinton’s reform effort failed. One major disagreement was over whether there had to be an individual mandate — Clinton’s plan had one, and Obama’s didn’t — but when he took office, Obama accepted that the mandate was necessary to make the entire plan work. It wasn’t a fantasy plan that just pandered to liberal hopes, it was something that could actually pass and be implemented.

Whenever liberals told Obama that a single-payer health plan would be far superior to what he was proposing, he would respond that if we were starting from scratch, that would probably be true. But, he’d say, we aren’t starting from scratch, so the ACA has to accommodate itself to the health care system that already exists. The result was a gigantic kludge, new complexity layered on top of an already complex system in an attempt to solve its varied shortcomings. Like all kludges, it seemed like the realistic option given the situation we confronted, but it left us with something that was far from perfect.

A Republican who actually wanted to pass real health care reform would have to approach the problem the same way: by saying that for better or worse, the Affordable Care Act has already affected the system in profound ways, so any realistic plan has to understand what those changes are, and find the most efficient way to keep the ones that are working and change the ones that aren’t. That doesn’t mean that repeal is impossible, just that it would be a spectacular upheaval, one that I promise you Republicans have no genuine appetite for. Remember all the screaming and shouting they did over the people on the individual market whose previous plans didn’t qualify under the new regulations, and who had to shop for new plans? Multiply that by ten or twenty times, because that’s how many people would likely lose their existing coverage if you repealed the ACA in one fell swoop.

And that would be only the beginning. So when any Republican candidate says he or she has a plan to reform health care, take a close look. If it starts with repealing the ACA — and it will — then you’ll know it isn’t serious and it’s never going to happen.

 

By: Paul Waldman, Senior Writer, The American Prospect; Contributor, The PlumLine, The Washington Post, August 20, 2015

August 21, 2015 Posted by | GOP Presidential Candidates, Health Reform, Obamacare, Republicans | , , , , , , | 1 Comment

“The GOP’s Obamacare Alternative; Crickets”: Now Railing Against Obamacare Without Having To Come Up With A Replacement

Now that the Supreme Court has saved the Affordable Care Act for a second time, what do Republicans do? We already know they won’t tone down their rhetoric and will continue to call for repeal because that’s what Republican primary voters want to hear. The candidates will package together vague alternative proposals that they will pledge to pass and enact as the first act of their presidency.

But they don’t have even a remote chance of repealing the ACA, even if a Republican is elected president in 2016.

“The ruling is the last gasp,” says Chris Jennings, a health policy expert who worked in both the Clinton and Carter administrations. While the presidential contenders will keep alive the hope for their base that if elected they can sweep away Obamacare, Jennings says the issue will be dead and gone by fall 2016. The voters will have moved on.

Conservatives feel betrayed yet again by Chief Justice John Roberts joining with the liberals on the Court to uphold the constitutionality of the ACA, but they should thank Roberts. He saved the GOP from having to bail out 6½ million people, the majority of them in red states, who would have lost their health insurance if the Court had ruled the other way.

Now Republicans can continue to rail against Obamacare without the responsibility of actually coming up with a law to replace it. “This decision gives them a vast canvas on which to write,” says Jack Pitney, a government professor at Claremont McKenna College in California. “There’s no need for immediate replacement, so rhetoric will fill the vacuum of legislation.”

There will be proposals, enough to satisfy the GOP faithful that the presidential candidates are doing something to end the abomination of Obamacare. But these will not be serious efforts because it is not possible to write health-care legislation that leaves in all the goodies everybody supports, like no discrimination for preexisting conditions, and leaves out what people oppose, like the mandate.

A reading of the majority opinion written by Roberts reveals that he paid close attention to the argument put forth by the health insurance industry in an amicus brief. Without the subsidies, millions could not afford coverage and only those with significant medical expenses would apply, sending the ACA into a “death spiral.”

The Roberts Court handed another lifeline to President Obama, but the decision is also a huge victory for the health industry. Asked how difficult it is for the GOP to step in with their own plan to counter Obamacare, Ceci Connolly, a Health Research Institute Leader and a former Washington Post reporter covering politics and health care, countered with some hard numbers. “The 2.9 trillion dollar health sector is exceedingly complex and changing; it takes an enormous amount of time and work,” she said. “Not only has the ACA expanded coverage, it has pumped billions of dollars in revenue to the health industry, and going back would upset a very large and important market.”

If the subsidies were removed or denied, it would have cost the health industry $36 billion in premium revenue next year alone, Connolly told The Daily Beast. Hospitals would have seen their revenue fall about $9 billion. While still a fraction in a huge market, “that’s real money to the industry,” she says. “The legislative process is cumbersome to say the least, and it would be a steep climb to replace the ACA.”

If a Republican president is elected, and the GOP retains the Senate along with the House, “that’s a new ballgame,” Connolly said. “But by 2017 the law would have been implemented for seven years. It’s very hard to take away benefits and significantly restructure a market as big as the health care market.”

Connolly noted that the executives her research group talks to around the country anticipated the decision to come down the way it did. “They could not imagine the subsidies being taken away.”

The phrase that political scientists use is “past dependency.” Once a major policy is entrenched, it’s very difficult to change in a major way. We’ve seen that with social security and Medicare, programs that President Obama invoked in his remarks in the Rose Garden about the ACA’s rite of passage into “the fabric of America.”

 

By: Eleanor Clift, The Daily Beast, June 25, 2015

June 29, 2015 Posted by | Affordable Care Act, GOP, SCOTUS | , , , , , , , | 1 Comment

“Antonin Scalia Defeated — By Antonin Scalia”: He Had His Own Previous Arguments Turned Against Him

Justice Antonin Scalia did not simply lose today’s key ruling on the federal health insurance subsidies for the Affordable Care Act — he had his own previous arguments turned against him.

The majority opinion issued today, written principally by Chief Justice John Roberts — whose crucial vote previously upheld Obamacare back in 2012 — illustrated the idea of the insurance subsidies being an integral part of health care reform itself.

And the absurdity of just striking out subsidies for people living in states with federally run exchanges — as Scalia and his fellow dissenters insisted had to be done under the law — was illustrated by citing… Antonin Scalia, from his earlier efforts to stamp out health care reform.

It is implausible that Congress meant the Act to operate in this manner. See National Federation of Independent Business v. Sebelius, 567 […] (SCALIA, KENNEDY, THOMAS, and ALITO, JJ., dissenting) […] (“Without the federal subsidies . . . the exchanges would not operate as Congress intended and may not operate at all.”).

That is, Roberts and company cited the dissent in the first major Obamacare case, from 2012, when the dissenters — Scalia being one of them — tried to say that pretty much each every single facet of the Affordable Care Act was not only wrong but unconstitutional, and that they interlocked so completely that by striking down even one of them, the entire Act would have to fall.

As a political staffer friend, who is a trained lawyer (though not currently practicing), tells me: “The problem with results-oriented jurisprudence is it makes hypocrisy easy to spot.”

The full paragraph in that original dissent is as follows:

In the absence of federal subsidies to purchasers, insurance companies will have little incentive to sell insurance on the exchanges. Under the ACA’s scheme, few, if any, individuals would want to buy individual insurance policies outside of an exchange, because federal subsidies would be unavailable outside of an exchange. Difficulty in attracting individuals outside of the exchange would in turn motivate insurers to enter exchanges, despite the exchanges’ onerous regulations. […] That system of incentives collapses if the federal subsidies are invalidated. Without the federal subsidies, individuals would lose the main incentive to purchase insurance inside the exchanges, and some insurers may be unwilling to offer insurance inside of exchanges. With fewer buyers and even fewer sellers, the exchanges would not operate as Congress intended and may not operate at all.

 

By: Eric Kleefeld, The National Memo, June 25, 2015

June 28, 2015 Posted by | Affordable Care Act, Antonin Scalia, King v Burwell | , , , , | Leave a comment

“Watch What You Pray For, You May Get It”: Republicans Have Boxed Themselves In A Corner On Obamacare

There’s an adage that perfectly captures the Republicans’ conundrum on Obamacare: Watch what you pray for; you may get it. Having spent the past five years viciously battling the Affordable Care Act, GOP leaders are worried that the U.S. Supreme Court may grant them a victory.

If the high court rules in favor of conservatives who have challenged the health care law — essentially gutting it — millions of Americans will lose the subsidies that allow them to purchase health insurance.

They’ll no longer be able to afford to see a doctor. They won’t be able to pay for knee replacements or chemotherapy treatments. They won’t have the money for drugs for hypertension and diabetes.

And they’ll be furious — just in time for the 2016 presidential election. Now that so many people have reaped the benefits of access to medical care, they want to keep enjoying them. They will be fighting mad if their health insurance is suddenly taken away.

That’s because the Affordable Care Act is doing exactly what it was designed to do. Consider a report from the highly respected RAND Corp. — a nonpartisan research group — which issued its latest judgment on the Affordable Care Act in May.

Its study found that nearly 17 million people now have health insurance because of Obamacare. In addition, families may keep adult children on their policies until age 26. There are no longer “lifetime caps” that limit the amount of money insurers will spend on the chronically ill. Patients are no longer turned down for health insurance because they are already sick.

“The Affordable Care Act has greatly expanded health insurance coverage, but it has caused little change in the way most previously covered Americans are getting health insurance coverage,” said Katherine Carman, who, according to a RAND press release, was the study’s lead author. In other words, the law didn’t wreak havoc on those who already had health insurance, as its critics had predicted.

It has slowly dawned on some Republican leaders that the law has provided tangible benefits to millions of Americans, and that they are likely to be blamed if those benefits are jerked away. But they have locked themselves into a very small room and lost the key. They can’t seem to find a way out.

President Obama noted the GOP’s intransigence in a speech to the Catholic Health Association a few days ago. “Once you see millions of people having health care, once you see that all the bad things that were predicted didn’t happen, you’d think that it’d be time to move on. It seems so cynical to want to take coverage away from millions of people,” he said.

But leading GOP officials have taught their aging base, many of whom are Medicare recipients, that the passage of Obamacare was tantamount to a communist takeover. Republican politicians have insisted for years that the Affordable Care Act would corrupt the health care system, ruin the economy and pave the way for a dictatorship. Now, they’d have a hard time persuading those voters, especially the Tea Partiers, it was all just extreme partisan rhetoric.

This latest high court challenge, King v. Burwell, is itself a symbol of Republicans’ determination to strip health care away from millions of Americans. (It’s also a sign of the partisanship that has overtaken the nation’s highest court, which should never have accepted the case.) It’s a frivolous suit that turns on the interpretation of four words in the statute — even though it’s perfectly clear what Congress meant.

If the court agrees with the challenger, chaos will ensue. The GOP will have to take responsibility for finding coverage for millions of people, although its fractious caucus is unlikely to agree on a fix.

Given the stakes, there are undoubtedly those among GOP elders who want the U.S. Supreme Court to maintain the status quo, even if they won’t say so publicly. After all, as Obama put it, “This isn’t … just about the Affordable Care Act. … This is now part of the fabric of how we care for one another. This is health care in America.”

Let’s hope at least five justices concur.

 

By: Cynthia Tucker, Pulitzer Prize Winner for Commentary in 2007; Featured Post, The National Memo, June 13, 2015

June 14, 2015 Posted by | Affordable Care Act, King v Burwell, Republicans | , , , , , , , | Leave a comment

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