November 1, 2013

The swirl of daily news now about the Affordable Care Act has increased so much now that the most important development has been overlooked: the Republican position of the last three and a half years, “repeal,” is now 100 percent dead.

That’s not on Sarah Kliff’s excellent list of 31 things we learned in the first 31 days of Healthcare.gov. It’s not in Sean Vitka’s story that for the first time in years more small businesses plan to add health care coverage for employees than to scrap it. Nor is it in the CBS story about how few people actually signed up in the first days of the exchanges. It’s not even in all the coverage this week of people’s plans being cancelled, and the back-and-forth about whether they’ll actually be better off.

And yet. Step back and add up all of it, and there’s one clear conclusion: repeal — flat out, go back to where things were in March 2010, that kind of full repeal — is totally dead.

True, we’ve known that politically since at least the 2012 elections. But I’m not even talking in terms of the politics of it, although that’s part of it. Just in practical terms, implementation of the health law (along with changes that happen over time no matter what the government does) mean that the system-that-was just is no more. Insurance plans have been cancelled, and new ones initiated. People have shifted coverage. Businesses have made new plans with ACA implementation in mind. That includes hospitals and doctors, and the rest of the health care industry.

No one is ever going to kick young adults off their parents’ insurance (or change the law so that insurance companies are allowed to do it). No one is going to bring back the various limitations in pre-ACA insurance policies. Some trimming of the new Medicaid rolls might be possible. But no one — no politician who has to face reelection, at least – is going to just toss all those people off their insurance with nothing to replace it.

Beyond all this is simply the Humpty Dumpty-ness of the situation: The old system has been slowly pushed off the wall for three years now, and by this point it’s really beyond repair, whatever the merits or politics of the situation. Garance Franke-Ruta captured some of this in making the point that delaying things would be impractical at this point, but it really goes beyond that. Too many people have already done too many things to make a full reversal even remotely plausible.

This hardly means that we’ve reached a stopping point in which Obamacare is safe, much less that serious health care arguments will end. Even if Healthcare.gov finally functions properly and the exchanges generally “work,” that doesn’t mean that serious reform efforts will end. Conversely, if implementation gets even uglier, then a next round of reform would be certain. It’s just that whatever comes next will be building on the ACA, not on the status quo ante. Because by now, that old status quo is just not around any more.

Democrats, of course, need to be hard at work getting the ACA to work as well as possible, but they’ll also have to begin preparing for those next rounds of the battle. Republicans, on the other hand, having utterly failed at formulating a “replace” plan when repealing and replacing was plausible, will need to see whether they can manage to come up with a way to transform the reality of the current situation into something they would like better. At least, if they want to be serious policy players they’ll have to do that. If they want to remain irrelevant, they certainly could just keep talking about “repeal” all they like. It’s just no longer an even plausible path from where we actually are.

Face it: Repeal is dead.