July 30

You may have noticed that the Medicare trustees have announced that the life of the program’s trust fund had been extended another four years to 2030 because of savings achieved through the Affordable Care Act. But you probably didn’t hear about this: The Obama administration has announced that because the ACA closed the Medicare prescription drug “donut hole,” since 2010, over 8 million seniors and disabled people have saved a total of $11.5 billion on medications, or an average of over $1,400 per beneficiary.

It was a good reminder that the ACA does a lot of things to improve the health system, not all of which make the front pages. And that has forced Republicans to come up with yet another way to keep alive the notion that someday we’ll finally get rid of it: Claim that it is only a matter of time until the law collapses on its own, making  and vow to have something or other ready to go in its place.

We’ll get to that in a moment, but in case you’ve forgotten, the donut hole was part of the prescription drug benefit passed in 2003 under President Bush. The way it works is that Medicare pays for much of your prescription drug costs up to the first couple thousand dollars, then stops paying entirely for the next few thousand dollars — that’s the hole, where beneficiaries had to pay for 100 percent of their drug costs — and then begins paying again after your out-of-pocket costs approach $5,000. The donut hole represented a huge hardship for millions of seniors, so the ACA closes it over time.

The donut hole sometimes comes up when you hear an administration official or some other Democrat give a long list of the good things the ACA has done for people. And almost all of the items on that list are benefits that Republicans would never risk taking away from voters.

Which is why actual repeal of the ACA would be so difficult for Republicans. You can talk about repeal in the abstract, and try to assure people that whatever they like about the law would still be there. But if you actually did it, you’d have to confront anger over the loss of all those particular provisions. And once you tell seniors you won’t re-open the donut hole, and tell cancer survivors that insurance companies will still be required to cover them regardless of their pre-existing conditions, and tell young people they can still stay on their parents’ insurance, and tell middle-income people they can still have the subsidies that enabled them to buy private coverage, and tell people that insurance companies will still be forbidden from rescinding their policy if they get sick or have an accident, all of a sudden it looks you’re repealing Obamacare and replacing it with…Obamacare.

So what’s a Republican to do? They’re faced with two unacceptable options. They could publicly admit that the ACA is here to stay (which they know by now) and bring on the wrath of their base, to whom they’ve been promising repeal for years. Or they could detail what “repeal and replace” would look like and open themselves up to blistering attacks from Democrats. The answer to that quandary is to promise that a detailed Republican health care plan is on its way, but never actually deliver it. To see how that works, we can look at this interview with Paul Ryan published in the Washington Examiner:

“I don’t think Obamacare’s going to survive anyway, because I think the law is so fundamentally unsound, that I think it’s going to collapse under its own weight in time, if anything. And so I do think we need to get ahead of that and propose a full repeal and replace — no, fully repeal and replace the law, ultimately. Is that going to be when the guy named Obama’s in office? No. But I think we need to get prepared for how to deal with health care reform.”

They need to “get ahead of that” — how forward-thinking and proactive, given that it’s been a mere four years since the law was passed and the GOP has yet to come up with its alternative. The interviewer tries just once to get Ryan to be specific, and is rewarded with an utterly meaningless free-market word salad:

Examiner: What should health care reform look like?

Ryan: It should be patient-centered, not government-run. That’s the basic core of it all … It should be a patient-centered system designed around the whole notion that the patient is the nucleus of the system, where all of the providers of health care services, be they insurers, nursing homes, doctors, hospitals, compete against each other for our business as consumers. And so we bring the basic fundamentals in a market economy to work in the health care sector, where they really haven’t been applied. And I think that is the core at getting at health inflation, accessibility and affordability, which is not only a family problem, because people are working paycheck to paycheck — it’s taking more of their disposable income away — but it’s also the core of our budget crisis.

Examiner: Is it enough for Republicans to say they’re going to repeal Obamacare, or do you need to communicate to voters that you’re going to fix health care broadly?

Ryan: Yes, I do believe it’s our obligation to articulate what we would replace Obamacare with and what the health care system would look like under our reforms and I really believe that more than ever before, the country is open to new possibilities and new ideas, and so, we should offer them.

In other words, they’ll be getting right on that. And thus it will be forever: the GOP “repeal and replace” plan will be always be coming soon, yet it will never arrive.