What’s the holdup, House Republicans? During the Obama administration, you passed literally dozens of bills to repeal all or part of the Affordable Care Act — knowing that none had any chance of being signed into law. Now that Donald Trump is in the White House, why can’t you seem to pull the trigger?
That’s a rhetorical question, of course. Republicans see that they have two choices: They can snatch health insurance away from millions of people, or they can replace Obamacare with something that looks suspiciously like Obamacare-with-a-different-name. Wary of both alternatives, erstwhile anti-ACA zealots have spent the first month of the Trump administration doing little more than clearing their throats.
The framework laid out by House Speaker Paul D. Ryan (Wis.) and other GOP officials last week is part capitulation, part evasion. In no way is it worthy of being called policy.
The surrender comes in the promise to keep the most popular features of Obamacare, which are a guarantee of coverage for those with preexisting medical conditions and a provision ensuring that dependents can remain on their parents’ insurance until age 26. Republicans accurately calculate that taking either of these benefits away would be politically suicidal — and that Trump, who has promised health care for “everybody,” probably would balk.
The evasion — let’s go ahead and call it dishonesty — is that the GOP framework promises not to “pull the rug out from anyone who received care” under the ACA’s expansion of eligibility for Medicaid, the federal health insurance program for the poor. But Republicans also plan to change Medicaid into a program of block grants to the states, with sharp reductions in federal funding.
In effect, House Republicans threaten to force states to do the dirty deed and strike millions from the Medicaid rolls. Governors from both parties are not amused.
The fundamental lie of omission in the GOP’s “repeal and replace” framework is the absence of any sense of what the new system would cost — or how it would be paid for. A plan without a budget is little more than a daydream.
Republicans do make clear that they want to eliminate Obamacare’s direct subsidies designed to help the working poor afford insurance. Instead, they prefer a system of tax credits, based not on income but on age. A 50-year-old billionaire would receive the same amount of tax relief as his or her 50-year-old gardener. Anything that makes our tax system even slightly less progressive warms the hearts of today’s GOP leaders.
But whether the federal government pays out more in subsidies or takes in less revenue because of tax credits, the reality is the same: Guaranteeing access to affordable health care is expensive. Republicans can decide it’s too costly and throw people off the insurance rolls, but if they do, they will pay a grievous political price.
Make no mistake, this has been a bad patch for the ACA. The chief executive of one health insurance giant, Aetna, opined last week that Obamacare has finally entered the “death spiral” that Republicans have so gleefully predicted. And officials of another mega-provider, Humana, announced that the firm will not participate in the Affordable Care Act exchanges in 2018.
That is called self-fulfilling prophecy: Republicans predicted from the start that Obamacare would fail — and then did everything they could think of to sabotage the program.
But in one crucial sense, the Affordable Care Act succeeded beyond anyone’s wildest dreams: It fundamentally changed the nature of the health-care debate in this country. Access to affordable health care is now seen as a right not just for the elderly and the desperately poor but for all Americans; and government is seen as the guarantor of that right.
The fact that Republicans pledge to continue protections for those with preexisting conditions, dependents up to age 26 and the 12 million individuals covered by Medicaid expansion illustrates how things have changed. The GOP once fought these provisions tooth and nail, calling them socialism disguised as compassion. Now the party embraces core elements of Obamacare as the new normal.
House Republicans have been hearing from constituents who would be bereft without the insurance they obtained under the ACA. A couple of GOP senators have even begun talking about repairing the law rather than replacing it. And whatever Congress eventually comes up with will have to pass muster with Trump, who promised to expand health coverage, not reduce it.
Republicans will win the battle over the “Obamacare” label. But Barack Obama already won the war.
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