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You are here: Home / Anderson On Health Insurance / The state of play on repeal and replace

The state of play on repeal and replace

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The Congressional session started today.  Today is Day 1 of the Repeal and Replace watch.  It could be a two year gig, a five year gig or a seventy three year gig.  We don’t know yet.  But we are seeing some of the mechanical parts initiated.

First from Morning Consult:

$1 billion dollars is a placeholder. That could be achieved by slightly tweaking any one of seventy three sections of the ACA. It is a nothingburger and a placeholder. It is also a hint that a rebranding and calling it victory is mechanically possible. If the reconciliation bill was filed with an instruction to save $1 Trillion dollars than that would be an indicator that a complete gutting would be one of the few plausible solutions to that specification. $1 billion dollars is going to be a massive undercount unless there are a bunch of additional tax cuts rolled into the rollback of coverage expansion subsidies but it is a marker that a rebranding is plausible.

Secondly, my initial one week reaction was wrong

I expect the filibuster to be gone by lunchtime on the first day of the new Congress.

I thought party whose agenda is unpopular and representing a minority of the voters would have removed a major procedural limit to their ability to implement and entrench significant portions of their stated agenda I was wrong. However the political incentives of at least half a handful of Republicans to either extract concessions or create plenty of situations where they can vote yes while hoping for a no upon which they can blame those obstructionist Democrats for not enabling a Heritage Foundation utopia to pass has saved the filibuster.

This, I think is the far more interesting thing today. Congressional Republicans and Trump can use reconciliation to roll back the taxes that fund the ACA immediately while sunsetting the ACA’s subsidies for an indeterminate number of years into the future without a single Democratic vote. They can’t roll back the insurance regulations without at least eight Democratic senators. I don’t trust the first few Democratic Senators to not sell out to gut the ACA in an attempt to protect their seat but I don’t think the 6th, 7th or 8th Democrat has a political incentive to gut the ACA. Without an agreement on the insurance regulations (and the cost sharing reduction subsidies), the individual insurance market will explode.

If the Democrats can hold firm where their agreement zone for at least eight votes in the Senate and a few dozen in the House is tweaks on the ACA that have been proposed in the past by Democrats such as the copper plan for a lower actuarial value plan, elimination of the employer mandate and technocratic tweaks that wonks have wanted, that is a plausible get. And if that is not what is being offered, the Republicans will have the choice of either blowing up the individual market or extending the sunset of the subsidies for another year or two.

If there is an agreeement that can deliver 37 Republican votes in the Senate and 160 in the House combined with 20 Democratic Senate votes and 100 in the House, it is a massive liberal ideological victory even in the face of an operational retreat of policy in a conservative direction. At that point the ACA is entrenched as a societal obligation to provide decent insurance to all citizens. The fights at that point will be over which dials to turn and how to implement.

I think this is the most optimistic that I’ve been in the past two months.

Update 1 clarified a sentence on the filibuster

Reader Interactions

109Comments

  1. 1.

    rikyrah

    Thanks for keeping me educated. I will spread the word. Do you have a list of DEM Senators that you think are weak and need contacting?
    Do you think that we should contact GOP Senators up in 2018?

  3. 3.

    Steeplejack

    @Richard Mayhew:

    Right on, bruh! You’re giving me hope. But get a grip on your bad self and clean this up:

    I thought party unity and a willingness of a concentrated minority party with complete power to jam through an agenda would have.

    Say what?

  6. 6.

    WJS

    If the Democrats can hold firm where their agreement zone for at least eight votes in the Senate and a few dozen in the House

    Honestly, why not throw the GOP an anchor while they’re drowning and “help” them repeal the ACA? It would be painful, and it would hurt people–I get that. But why not focus on taking control of Congress by showing people exactly how awful things are under Republicans?

    But, then again, maybe not. The worse Republicans make things, the more votes they get. I think I answered my own question.

  7. 7.

    zzyzx

    @Steeplejack: I think that means that more people voted for Democrats in the House, the Presidency and (likely) the Senate, but the way the EC and the gerrymandering has worked, the Republicans control them all.

  9. 9.

    Sister Rail Gun of Warm Humanitarianism

    @rikyrah: Here’s a place to start. Senators up for reelection in 2018 in states that Trump won: Baldwin, Brown, Casey, Donnelly, Manchin, McCaskill, Nelson, Stabenow, Heitkamp, Tester.

  11. 11.

    Hunter Gathers

    The innate incompetence that permeates the Conservative movement makes me wonder if it will even get through the House. The Freedumb Caucus may not vote for it unless it re-instates chattel slavery.

  12. 12.

    ruckus

    Richard, I hope you are correct or at least close.
    That might mean that the world is not coming to an end, just getting a bit uncomfortable for a while and we have a chance to move the bar back farther than it is today.

  13. 13.

    Brachiator

    Thanks very much for this. I taught a class on ACA to a group of tax preparers today. There were a few questions about possible repeal, and I could only say, “at this point, we do not know what Congress might do.”

    It is very interesting to see that, for now, Democrats may have some power with respect to the promise of immediate repeal.

  16. 16.

    zzyzx

    @WJS: Because politics isn’t a game, it’s about helping people out. I don’t care about Democrats getting elected because I like them or Republicans being defeated because I think they have a dumb name. All I care about is policy. If Republicans are not going to engage in destructive behavior that will hurt a lot of friends of mine, I’m going to encourage that rather than hope for a short term disaster in hopes of a utopia that might never come.

  17. 17.

    Yarrow

    I thought I read something about Rand Paul saying he wasn’t going to vote for repealing the ACA without something to replace it with. Now I can’t find that. Anyone else know?

  18. 18.

    gene108

    I remember when the ACA was up, in 2009, how businesses kept saying they could not handle all the regulatory uncertainty from rapid rules changes.

    I hope they will use the same reasoning against all the upheaval Republicans have promised.

    /sarcasm

  20. 20.

    Sister Rail Gun of Warm Humanitarianism

    @debbie: I pulled that list from a “Let’s let them know we have their backs” discussion on the cabinet nominations. I don’t think Baldwin of Wisconsin is likely to be a problem, either. Manchin, OTOH….

    While I’m on the subject of the cabinet, has everyone heard about the ALNAACP occupying Sessions’ office in Mobile?

  24. 24.

    trollhattan

    Guessing we’ll have a month or two of fox battles over what to do now that they rule all of the henhouse. Some foxes will be harmed, some foxes will not get what they want, all hens are fvcked.

  25. 25.

    Sandia Blanca

    Hi Richard, can you please advise whether this story is in line with your understanding? (I confess some of this is over my head.) Thank you!

  28. 28.

    Enhanced Voting Techniques

    @Hunter Gathers:

    The innate incompetence that permeates the Conservative movement makes me wonder if it will even get through the House. The Freedumb Caucus may not vote for it unless it re-instates chattel slavery.

    Not to mention their impulse to vote no on everything.

  31. 31.

    Groucho48

    There’s a Diary, over on Kos, discussing that, if Republicans do use reconciliation to do away with as much of Obamacare as they can, it will likely lead to the collapse of the individual market. Congress and Congressional staffers plus various executive branch folks, are required by the Grassley Amendment to Obamacare to buy their insurance on the individual market.

    That could give Republicans something to ponder.

  34. 34.

    Richard Mayhew

    @Sandia Blanca: Pretty much in line with my understanding. The GOP can take away subsidies and the taxes that fund the ACA as well as zero-out the mandate without a single Democratic vote. They can’t change the insurance regulations on their own. And if they keep the insurance regulations with no subsidies and no mandate, either rates triple or no insurers will offer coverage in most states.

  37. 37.

    Jeffro

    @Baud:

    Remove the Stone Mandate of Shame.

    Attach the Stone Mandate of Triumph!

    OMG that is too fucking funny.

    So…we’re basically calling it Trumpcare, and lowering ACA taxes on the rich a bit? GOP’s declaring victory and going home?

  40. 40.

    WJS

    @raven: Yeah, I couldn’t bring myself to reply to that.

    The people who voted for this are the ones who cut off their noses to spite their faces. I’m not sure why the Democrats should enable the Republican effort to enlarge their electoral gains and drive home the fact that government does not work.

    Fighting that sometimes mean you let them have exactly what they want so that they “own” the repeal of Obamacare.

  43. 43.

    Jeffro

    @Richard Mayhew:

    And if they keep the insurance regulations with no subsidies and no mandate, either rates triple or no insurers will offer coverage in most states

    Ah, so they’re not lowering the ACA taxes a bit, they’re eliminating them and putting the cost on to people on the exchanges (if any plans are even offered on the exchanges). And without Obamacare’s various provisions in place, health care costs start going back up for everyone.

    From the Vox article:

    The Congressional Budget Office has declared that it will score legislation that replaces people’s comprehensive health insurance with much weaker catastrophic plans as equivalent to taking away their health insurance altogether.

    That makes it likely that most Republican replacement plans, which rely heavily on making insurance skimpier and therefore cheaper, will be scored as taking insurance away from millions of people, spurring public opposition before they come up for a vote and risking still greater public outrage when they actually come into effect.

    Why don’t Dems just run a simple, two-part ad:
    1) [quick picture sequences of Obama & Dems signing Obamacare, then pics of Americans from all walks of life] “When it was introduced, Republicans warned about that horrible, terrible, no good, very bad, job-killing Obamacare…and our economy went on to produce the strongest unbroken record of growth in our nation’s history. Over 20M people got health insurance, pre-existing conditions were covered, and kids could stay on their parent’s insurance until they turned 27.”
    2) [odometer-style counter quickly racking up numbers in the millions and tens of millions] “But now Republicans in Congress have decided that even when something works and works well, if it was enacted by Democrats, it has to go. And not just for those 20M people who now have health care…but in exploding health care costs for everyone, including working families and seniors. Call your MoC now and let him/her know where you stand.”

  45. 45.

    raven

    @WJS: I asked my 20 something, very liberal nephew, if he wanted Trump to totally fail. He said “no, I work in advertising, I’m part of the system. I don’t want it to collapse”.

  50. 50.

    trollhattan

    O/T Nor/Cal is in the midst of a classic winter storm the likes of which we’ve not seen for half a decade. Continual rain and cold, so generating snow in the mountains. I remember when this was SOP, now it’s cause for celebration and telling small children “it’s okay, it’s just winter like lucky people get.”

  52. 52.

    Jeffro

    @Major Major Major Major: True, but per my further reading it looks like they’re going to do a lot worse…eliminating the mandate and funding means that all those folks on the exchanges will now have to pony up for what will likely be very skimpy plans.

    Gonna be a whole lot of GOP lyin’ going on about how, to reinstate full/better ACA-style coverage, the middle class will have to take it in the shorts. No mention will be made that it was doing pretty well as it was when funded primarily by higher taxes on the very well off.

  53. 53.

    JPL

    @raven: A friend complained that the ACA policy increases hurt her son and his family. Truth be known, she and her husband pay his portion anyway. I said why not tell him just to buy insurance without ACA. She mentioned that would be too expensive. Yup.. That’s your average Trump voter.

  54. 54.

    Jeffro

    @efgoldman: Minus the chain saw, EF’s right – let’s fight them tooth and nail. If they still beat us (for now), THEN they can “own it”. But let’s not just surrender on this.

    I think we push on MoCs (R and D) to explain exactly what is so bad about Obamacare that it needs to be destroyed? 20M people covered. Cost curves bent and bent hard (for everyone, not just those 20M). Economy booming despite all the “job-killing Obamacare” BS. Why would we change that, other than to lower taxes on the 1%?

  55. 55.

    Jeffro

    @JPL: Yeah, it’s like we never had rate increases in health insurance before Obamacare came along, right? Everything was fine and dandy, medical care was cheap, insurance companies came to our houses and turned down the beds every night.

  58. 58.

    Major Major Major Major

    @Jeffro:

    No mention will be made that it was doing pretty well as it was when funded primarily by higher taxes on the very well off.

    This is not entirely accurate! The subsidies were way too low, but it’s all we “can afford”.

  59. 59.

    Yarrow

    @Jeffro: Honestly, this is totally what they should do. Make some tiny change, rebrand it as “Trumpcare” and crow about how much better it is than that evil Obamacare and move on. The dumbasses who want “Obamacare” repealed would never know the difference. It would be a total win for Trump because he “brought them healthcare.”

  61. 61.

    Ohio Mom

    I remain most concerned about Medicaid. That’s the program with the least powerful constituencies: the disabled, poor people, poor elderly, with a lot of overlap among those categories.

    As I understand it, the plan is to go from the current funding system where the Feds match each state’s contribution to a block grant, which will end up strangling Medicaid. Where will the push back for that come from?

  62. 62.

    Jeffro

    @efgoldman: Re: making MoCs explain what’s so bad about O-care

    In theory, you’re right. But remember that RWNJ Republiklowns, very much including congress, lice in fantasy, non-reality, non-fact, “truthiness” land. Facts are just fungible concepts, not to be used for “thinking” or decision making.

    I hear you…I just want the whole country to hear exactly how deluded and/or malicious and/or deceitful these people are first hand. Let them claim they had to destroy the village in order to save it and let’s see how that goes over in 2018.

  63. 63.

    Jeffro

    @Ohio Mom:

    As I understand it, the plan is to go from the current funding system where the Feds match each state’s contribution to a block grant, which will end up strangling Medicaid. Where will the push back for that come from?

    Your understanding is correct and the push back will come from Dems (first our outnumbered MoCs and then ideally from our outraged voters).

    I hate to tip our hand but along with fighting the GOP on each of these horrible ideas, we also ought to publicly thank them for helping us with voter registration for 2018 and 2020.

  65. 65.

    Jeffro

    @efgoldman: Of course I’m serious. The GOP and Trump ran on getting rid of Obamacare BUT somehow keeping all of its popular elements (which as we know is not do-able). Point out to people that it is working relatively well (especially on the jobs front) and that not only will 20M people lose health coverage but EVERYONE will be hit with rate increases, just so that the 1% get their ACA taxes lowered, and it might swing the argument.

    As for the rest, none of these GOP goons nor Trump ran on voucher-izing Medicare, starving Medicaid, or privatizing Social Security. What will they say to a million “America, You Didn’t Vote For This” ads?

  68. 68.

    hovercraft

    @Ohio Mom:

    As I understand it, the plan is to go from the current funding system where the Feds match each state’s contribution to a block grant, which will end up strangling Medicaid. Where will the push back for that come from?

    From the nursing homes and the elderly care facilities, which are paid for by Medicaid. Also it will come from all of those WWC people and their bosses, when they realize that Noni and Pop-pop are moving in, without Medicaid to pay for it, very few people can afford to live in assisted living facilities.

  72. 72.

    hovercraft

    @Major Major Major Major: @Yarrow:
    While I agree with Major that they have no interest in helping people, they do have an interest in keeping their jobs. Most people have no idea what’s actually in Obamacare, it’s just that terrible thing that Obama did to our great healthcare system, so all they have to do is do some cosmetic tweaks, change the name and say they repealed it and the rubes will love it. After all most of them already do.

  74. 74.

    JPL

    @hovercraft: ACA was funded by tax increases to the one percent. The first thing the repubs will do is rid their friends of that pesky tax increase. The unraveling of Obamacare and Medicare will then begin.

  75. 75.

    GregB

    We should tell people how they can spend some real quality time with their parents picking out a new insurance from among hundreds of options instead of dealing with the oppression of the simplicity of Medicare thanks to the ethics dodging Republicans.

  76. 76.

    Baud

    @GregB:

    We should tell people how they can spend some real quality time with their parents who will now be living with them

    Fixed.

  81. 81.

    Cacti

    @JPL:

    ACA was funded by tax increases to the one percent. The first thing the repubs will do is rid their friends of that pesky tax increase. The unraveling of Obamacare and Medicare will then begin.

    Or they could do a Reagan and pass some regressive tax increases to shift the burden downward.

    Whatever it takes to make America great again. ;-)

  83. 83.

    Yarrow

    @hovercraft:

    when they realize that Noni and Pop-pop are moving in, without Medicaid to pay for it, very few people can afford to live in assisted living facilities.

    Someone (maybe Botsplainer?) said at some point that most states have laws REQUIRING children to care for their elderly parents. Even if those parents abused you or did other awful stuff to you, you’re still required by law to care for them.

    If that’s true, let’s get that in a TV commercial and run it nonstop. Show the nice men in the nursing home van dumping mom off on your doorstep because Medicaid can’t pay for her care anymore. Show the scared elderly woman who needs 24 hour care. Show the overwhelmed family members with both parents and grandparents in the living room needing care. Talk about Republicans taking away people’s dignity. Show it all.

  84. 84.

    Elizabelle

    Watching PBS. Seems to be an American Experience about Sidney Lumet. Speaking of 20th century Jewish theatre, and his father’s experience with it.

    Tweety-free!

    ETA: Trigger alert, though: 10 p Frontline is “President Trump.”

    Where are Twilight Zone reruns when you need them?

  85. 85.

    cynthia ackerman

    @Ohio Mom:

    I have a sister who is dependent on Medicade.

    I think the affected constituency is people like me who will be forced to replace gov’t support.

    A smart response to Medicare “reform” could do worse than to target us.

  86. 86.

    JMG

    The Republicans in Congress are a collection of fanatics and venal grifters. Some are both. What we saw today, however, shows us they’re none too courageous nor bright. So it’s going to take them awhile even to figure out how to proceed. They’ll speak as if every day is a major triumph, but not all of them will be. What could be most damaging for them is if someone gets it in the new President’s head that what comes after Obamacare inevitably will be called Trumpcare.

  90. 90.

    Central Planning

    @trollhattan: Heard from a cow-orker today on the west coast that they were expecting something like 11 inches of rain between tonight and Saturday. Some mountains were going to get 90″ of snow. Sounds awesome!

  91. 91.

    hovercraft

    @Yarrow:

    Someone (maybe Botsplainer?) said at some point that most states have laws REQUIRING children to care for their elderly parents. Even if those parents abused you or did other awful stuff to you, you’re still required by law to care for them.

    WTF ?
    We all remember those tales our parents and grandparents told us about all the hardships they had to endure growing up? Walking five miles in the snow to and from school, barefoot. Perhaps since most of our horror stories involve first world problems now, they are granting us the opportunity to regale our grandkids with our real tales of woe. It was just a few years ago when there were reading about and seeing cardboard cities spring up because of the foreclosure crisis. If they hit the trifecta and are able to repeal Medicare, Medicaid and Obamacare. Nana has no teeth left because it costs too much to fix the old ones, and my job at the grocery store doesn’t pay enough for me to get new ones. Kids can tell their friends that Grampa lives in the shed out back because Mommy and Daddy say he likes to touch little kids, so he can’t come in the house.

    They really seem to be intent on taking our country back.

  93. 93.

    hovercraft

    @efgoldman:

    I found it in Corner Stone’s garage; i don’t own one.

    Next to the garlic he keeps for when he wanders around naked? Yeah, yeah I know, the “AC” was broken.

  95. 95.

    Lizzy L

    @efgoldman: Approximately 27% of the eligible voters in this country voted for T. A slightly larger percentage voted for HRC. That leaves at least 40% of eligible voters — people who could have voted for either candidate, and didn’t vote. (I’m pretending Jill Stein and Gary Johnson don’t exist.) The ones who voted for T: assume they’re hopeless. The ones who voted for HRC: they know the score. It’s the ones who didn’t vote that we need to talk to. Mom and Pop (or your diabetic older brother, or your mentally-ill son) moving in because their health insurance is gone and they sold the house to pay for care is a powerful, powerful argument.

  97. 97.

    AnotherBruce

    @efgoldman: There’s 325 million people in the country, and more voters for Hillary than for Trump. Quit giving the minority of white shithead Trump supporters the agency they don’t deserve

  98. 98.

    WJS

    @efgoldman: Well, alrighty then. You act as though I ran on repealing Obamacare. I did not. But the American people need to understand the correlation between being willfully misinformed and seeing their government benefits turn to dust before their eyes. We are not going to get to the other side of this unless a whole lot of people wake up and start educating themselves as to who will help them (Democrats) and who will rob them so billionaires can have extra houses (Republicans).

    As soon as Trump won, and as soon as the GOP held the Senate and the House, everyone with a brain knew that Obamacare was dead in the water. They’re going to laugh while they kill it because they don’t care about regular human beings and their suffering.

  99. 99.

    Ohio Mom

    @cynthia ackerman: I have a kid with a disability who I hope will be dependent on Medicaid one day. Medicaid being what pays for group homes, transportation services, day programs, etc.

    I’d like to think that families with members who need Medicaid will rise up but in my experience, most of them don’t get it. Maybe because I live in Ohio and am surrounded by many Republicans?

    They think that no one would do anything to harm “our kids.” Well, perhaps coming events will dissuade them of that notion…I’m going to do my best to create what cognitive dissonance I can.

  100. 100.

    zzyzx

    @WJS: And if it makes my friend who worked hard for Clinton and might die if health insurance is taken away collateral damage, oh well? Fuck that.

  101. 101.

    hovercraft

    @Percysowner:
    These morons are um, morons.

    “He obviously hasn’t read these opinions,” Jost said. He pointed to National Federation of Independent Businesses v. Sebelius, which Jost said “contained very strong statements about state rights;” King v. Burwell, which “included language in which the court basically limited deference to administrative agencies;” and Burwell v. Hobby Lobby, which “was all about religious liberty.”

    “These are three precedents that one would think Representative King would affirm very strongly,” Jost said.

    I will co-sponsor this legislation, what you say, I’m not a member of congress, so what, my suggestion makes about as much sense as a congresscritter suggesting that he can dictate what precedents the Supreme Court can cite.

  102. 102.

    tonycpsu

    @Richard Mayhew

    If the Democrats can hold firm where their agreement zone for at least eight votes in the Senate and a few dozen in the House is tweaks on the ACA that have been proposed in the past by Democrats such as the copper plan for a lower actuarial value plan

    Proposal To Add Skimpier ‘Copper’ Plans To Marketplace Raises Concerns

    I mean, okay, it would technically be insurance, but the article mentions that bronze plans didn’t sell well, so why would copper plans? And how does this not get us into a race to the bottom where they create “iron”, “aluminum”, and “rusted Ford Pinto body panel” plans with even crappier coverage?

    Bronze is already skimpy coverage — I don’t think Democrats should be any party to a further erosion of the minimum ACA plan standards. For the exchanges to be worth fighting for at all, they have to provide coverage that actually covers something when people get sick.

  103. 103.

    James Powell

    Here’s the thing: The Republicans could repeal ACA in toto then re-enact it, call it TrumpCare and 70% of the country would approve of the new and much better than that black guy’s health insurance program. The only person in the press/media to point out that it was only a name change would be Paul Krugman. Trump & FOX would call him a sore loser. CNN & MSNBC would say, “Well, that’s how it looks.”

    All the #BernieorBush people would agree.

  104. 104.

    WJS

    @zzyzx: If you want to break the hold on power now held by fascists, people are going to have to die. If they repeal Obamacare, some 45,000 Americans are going to die each year. I don’t want that to happen. But spare me the outrage–far too many Americans voted for Trump knowing full well that kids would starve if their SNAP benefits were taken away, sick people would die because their Obamacare was taken away, and soldiers would die fighting in a war started by an errant tweet.

    This is what those fuckers voted for. This is the world they wanted. And they don’t care who has to suffer. There’s no magic pony who is going to save Obamacare now that they control the Executive, the Legislative, and soon the Judiciary. If you want to yell at someone, yell at Jill Stein.

  105. 105.

    Glidwrith

    @WJS: No, you sick puppy, people are not going to have to die to bring about the revolution you seem to be advocating. Will some die because of the policies the fascists enact? Possibly, but there is an enormous amount of power and influence that will be brought to bear before those policies are law and we can mitigate the consequences. I, for one, will not stand aside because too many innocents will be caught up in the bloodbath.

    Enough people will die, despite our best efforts, to break these asshole’s power without us adding to the butcher’s bill.

  107. 107.

    WJS

    @NobodySpecial: No, I want people to realize that we just had an election that was decided by people indifferent to having people die. People voted for something awful. That’s what we’re up against.

    Sheesh.

  108. 108.

    NobodySpecial

    @WJS: We already knew that, moron. And my point is the same: You want the world to burn for politics? Set yourself on fire first, as a healthy example.

    Seriously, done with morons like you.

  109. 109.

    WJS

    @NobodySpecial: The President agrees with me. SO glad you’re done with us…

    In the closed-door meeting, the President urged fellow Democrats to not “rescue” Republicans by helping them pass replacement measures, according to sources in the room.
    He also floated this idea: Start referring to the GOP’s new plan as “Trumpcare.”
    The suggestion was a clear indication of the Democratic Party’s goal of turning the tables on Republicans, who are already facing pressure to quickly craft a replacement bill.
    As he walked by a scrum of reporters, Obama would only say this about the Democratic Party’s message: “Look out for the American people.”

    Fuckwit.

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