Is the GOP ACA Repeal Strategy Taking Shape?

GOPThere’s politics then there’s governing. As former New York Governor Mario Cuomo put it, “You campaign in poetry. You govern in prose.” Republicans have been campaigning against the Affordable Care Act since its enactment with rhetorical flourishes along the lines of “repeal and replace” and “end Obamacare on Day One.” That is poetry (or at least what passes for poetry in politics). Come January, Republicans will need to prove they can handle the prose part. As discussed in my previous post, that won’t be easy.

Repealing the law outright would cause chaos in the health insurance marketplace and take medical coverage away from millions of consumers. However, doing nothing would break a promise central to the GOP’s electoral successes in the past four Congressional elections, not to mention the most recent presidential campaign. Either path could lead to voter retribution that would be devastating to the short- and long-term interests of the Republican party.

A GOP strategy may be emerging that aims to avoid this rock and that hard place. The idea involves passing repeal legislation as close to President Trump’s first day in office that is legislatively possible, but delaying the effective date of that legislation by a year or two. This enables Republicans to keep their promise to repeal Obamacare “on day one,” yet gives them time for the more difficult task of working out a replacement to the ACA. It’s a political two-step Joanne Kenen has dubbed “TBDCare.”

Yes, this would cast a dark cloud over the health insurance market for some considerable time and raises a host of questions: Is Congress capable of passing workable and meaningful health care reform? What happens if they don’t? What would those reforms look like? Who would the winners and losers be under Republican-style reform?  Not knowing the answers to these questions is terrifying. For GOP leaders trying to avoid the wrath of voters, however, living under a frightening dark cloud for a couple of years might look better than ushering in the health care reform apocalypse.

The repeal part of this two-step strategy is simple: Republicans in Congress eviscerate the financial mechanisms critical to the ACA through the budget reconciliation process. This type of bill requires only 51 votes, which means no Democratic support is needed. Meanwhile, President Trump dismantles other elements of the law by either revoking President Barack Obama’s executive orders or issuing new ones. Both the legislation and executive orders become effective at the end of either 2017 or 2018 to allow for a “smooth transition.”

Then the replace portion of the program would begin. Much of any new health care reform legislation would need to go through the normal legislative process and be completed before the effective date of the repeal. Given the Senate’s filibuster rules this means securing at least eight Democratic votes in the upper chamber. (Here’s a list of the Democratic Senators most likely to be recruited by Republicans).

Both Jennifer Haberkorn on Politico.com and Albert Hunt on Bloomberg.com do a great job in reporting on this evolving strategy.  Meanwhile, opposition to TBDCare is already building as evidenced by this editorial in the Denver Post.

What should not be overlooked in all this pain aversion is that the Affordable Care Act was neither the cause nor the solution to America’s deep-seated health care problems. Long before Senator Obama became President Obama everyone knew the key to successful health care reform was reducing medical costs. A few provisions in the Affordable Care Act address costs, but the legislation focused primarily on health insurance reforms because, well, reforming the health insurance market is a lot easier than reducing health care costs. If you were a politician, who would you rather take on, insurance companies or doctors, hospitals and pharmacy companies?

Whether using poetry or prose then, it would be nice if, once they get past the politics of health care reform, Congress and the new Administration addressed the substance of health care reform. Let’s hope that’s not asking too much.

Please check out my magazine on Flipboard for a curated collection of news and opinion concerning health care reform.

 

4 thoughts on “Is the GOP ACA Repeal Strategy Taking Shape?

  1. Thanks, Alan. Re Medicaid, what I was asking your opinion on isn’t whether the expansion as it exists now would be “repealed” or not, but whether that possible 1-2 year delay in effective-date is likely to apply to Medicaid as well.

    Also, regarding the off-marketplace individual plans, one thing I’ve wondered if those plans are also included in the 20-million “Obamacare-insured” number that is often bandied about. If not, the magnitude of possible coverage-loss from repeal is being understated.

    • Good questions. Concerning Medicaid, my guess is that’s the kind of questions they’re thinking through in the Republican caucus. If they go forward with TBDCare it will become clear in December and we’ll know about Medicaid then. As for the 20+ million insured as a result of the ACA I believe it counts all coverage — Medicaid, through the exchanges, and outside the exchange. Maybe someone else out there can be more definitive about it, but I’m pretty sure that’s the case.

  2. Interesting. From a 100% self-centered viewpoint, as a self-employed individual who has about 1.7 years to go until Medicare eligibility, the “repeal now, pay later” plan sounds very promising. (Of course, who knows what is going to be left of Medicare if Ryan gets his way…)

    But as much trouble as the marketplaces had this year with insurers like Aetna and UHC dropping out, what incentive would insurers have to maintain — let alone step up — participation in 2018? Maybe even the Blue Crosses would bail, leaving little but the ultra-narrow, lowest-cost players like Centene and Molina that actually profit from the marketplace. (You know, the guys that caused subsidies to plummet in some areas by causing the second-lowest-Silver premium to nosedive? Budget-conscious Republicans should have welcomed them for dramatically reducing federal subsidy expenditures.)

    Also, would “repeal now, pay later” include Medicaid as well?

    • Hello Rick. Yes, a lot of carriers pulled out of the exchanges this year, but remember, the individual insurance market is far bigger than the exchanges. If the GOP were to immediately repeal what they can through the reconciliation process and executive orders, but without a delayed effective date or concurrent replacement, carriers would likely drop out of the individual market altogether in order to avoid the adverse selection of having to accept consumers with pre-existing when those consumers are not penalized for going without coverage until they need it. That’s the danger.

      As for Medicaid, yes it is likely the GOP would try to cut back on the Medicaid expansion promoted by the ACA. And given that President-Elect Trump has called for replacing the current federal payment to the states for Medicaid with block grants to the states, we could see that program cut way back.

      Far from a pretty picture, however you look at it.

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