If the Trump administration prevails, everything in the law would be wiped out. And I do mean everything: the protections for people with preexisting conditions, Medicaid expansion, income-based individual-market subsidies, provisions allowing children to remain on their parents’ insurance until age 26, requirements that insurance cover minimum essential benefits such as prescriptions and preventive care, and so on.
The administration’s rationale was laid out in a policy brief supporting a lawsuit challenging Obamacare by 20 red states. Their logic: When Congress, as part of President Trump’s 2017 tax cuts, set the penalty for not carrying health insurance to zero, that effectively made it no longer really a “tax,” and therefore made it unconstitutional. Somehow, that rendered the rest of the law unconstitutional, as well — including lots of provisions having nothing to do with the mandate.
This reasoning has been rejected even by conservative legal scholars otherwise opposed to the law. But legal merits (and demerits) aside — which are likely to be ultimately adjudicated by the Supreme Court — it’s also not clear what political upside Republicans could possibly see in mounting yet another overt attack on Obamacare.
The GOP’s November congressional losses were largely motivated by voter rage over the party’s attacks on Obamacare, after all. Trump has, of course, more recently proclaimed the GOP the “party of health care,” and he and other party leaders continue repeating the obvious fiction that they’re cooking up “something terrific” to replace the ACA.
Yet Trump’s party has never been able to come up with (let alone pass) a viable replacement plan, even when it had unified control of government.
There are more productive things Trump and lawmakers could do to improve the health-care system that don’t involve dismantling the ACA. Obamacare, after all, did a lot to expand coverage and not nearly enough to improve affordability.
In fact, if Republicans are looking for more fruitful areas for improvement, they might contemplate a survey focused on employer-sponsored insurance plans that was released Thursday by the Kaiser Family Foundation and the Los Angeles Times.
About half of the U.S. population has employer-based coverage, including 60 percent of nonelderly adults. While most say they are generally satisfied with these health plans, many nonetheless struggle with the financial burden they impose — particularly the high-deductible plans that cover 4 in 10 people with employer-sponsored insurance.
Deductibles in employer-sponsored insurance have been rising since long before the ACA. They have nearly quadrupled over the past 12 years and now average $1,350 for a single-person plan. But separate survey data show that only half of nonelderly, one-person households report having at least $2,000 in savings available.
It’s no wonder, then, that many with “good” health coverage still report trouble paying for care. In fact, half of adults with job-based coverage say they or someone in their household has skipped or delayed getting medical care or filling prescription drugs in the past 12 months because of the cost.
Figuring out how to reduce out-of-pocket costs — including deductibles so high that they’re tantamount to not having insurance at all — turns out to be much more challenging than simply burning down the entire system. After all, requiring employers to spend more on health insurance might just end up hitting workers in the form of lower wages.
Even so, there are promising paths forward.
For instance, the latest version of a plan known as the Medicare for America Act — introduced Wednesday by Reps. Rosa L. DeLauro (D-Conn.) and Jan Schakowsky (D-Ill.) — would create an expansive public insurance option to compete with the employer-sponsored system. The public option would cap premiums and out-of-pocket costs and have no deductibles. The bill would allow employer-sponsored plans to continue, as long as they covered a minimum average share of enrollees’ health expenses.
Other options might include refundable tax credits to offset out-of-pocket spending, as have been proposed by Democrats before.
Trump administration officials may not like these alternatives. Fine. But if they’re going to persist in trying to blow up the current system — through administrative sabotage, funding cuts and bogus court challenges — the onus remains on them to propose better ways to rebuild it.