I’ve been slowly moving towards only pessimism(75%) instead of certain(97%) that the ACA or something like is doomed.
I want to go over why my thinking is evolving.
My first piece of new evidence that changed my perspective is the retention of the filibuster. Part of that is to force the Democrats to the table in a Repeal and Replace cliff but also because it gave marginal Republican Senators a good bit of power and say over final final policy.
Two conservative wonks who actually know what they are talking about had a good Health Affairs article on the problems with Repeal and Delay:
An immediate repeal of the individual mandate’s penalty will lead some younger, healthier enrollees in ACA insurance plans to stop paying premiums. Even if the number of those dropping out in 2017 is small, it will be lead to further losses for insurers, and make it even more difficult for them to justify continued participation in 2018. There is a real danger that many parts of the country would be left with no insurance plans at all offering coverage on the ACA exchanges in 2018.
If Congress delays enacting a replacement plan, uncertainty about what might be in that legislation would further destabilize the exchange market even if ending the tax penalty for non-enrollment is tied to the ending of the premium credits and cost-sharing subsidies. Some number of current exchange enrollees, as well as insurers, are likely to view the coming termination of the ACA as a reason to withdraw their participation. Consumers may think they will eventually be spared any tax penalty even if they drop out of coverage, and insurers (and their shareholders) are likely to think it is unwise to make any kind of continued investment in a program that could soon disappear…..
But a plan that is focused on repeal without a clear vision for what will come next, or how it will be enacted, could easily backfire. There are numerous political, budgetary, and procedural obstacles to moving forward with an effective program to replace ACA.
To build a functioning marketplace, and to provide a ready path for all Americans to get health insurance, it is necessary to put together a coherent series of policies across Medicaid, employer-sponsored insurance, and the non-group insurance market. A workable plan will necessarily touch on all of these areas, and will be lengthy and politically contentious….
Jonathan Chait has been counting noses in the Republican Senate caucus:
Republicans need a House majority, 50 Senate votes, and soon-to-be President Trump to pass repeal and delay.
If Republicans lose three Senate votes, that drops them to 49, and repeal and delay cannot pass. At least three Republican senators (in addition to all the Democrats) now oppose repeal and delay. Rand Paul, of all people, has demanded that Congress repeal Obamacare at the same time it passes a plan to replace it. Paul has announced that he spoke with Trump and secured his agreement on this. Trump has not said so himself, confining his comments to date to a vague assurance, “That’s all gonna work out.”….
Even more ominously for the Republican leadership, four other Republicans have joined Corker to sponsor a bill delaying the bill that would repeal Obamacare for a month….
And then we get statements like the following:
Sen. Shelley Moore Capito (R-WV) tells me she wants an Obamacare replacement to cover MORE people than Obamacare. https://t.co/zEF4ORMfi3
— Sahil Kapur (@sahilkapur) January 9, 2017
The way Repeal and Replace was supposed to work was that a fait accompli would be delivered very early on with little dissension and the facts on the ground that the ACA was gone in twenty one months and Replace has to get passed with Democratic votes. We’re getting dissension. There is still a very good chance that something is going to pass as Repeal(ish) but the reality that healthcare is complex is becoming real to Republicans who actually have to look at policy results on their voters is moving me from the depth of despair to only pessimism.
NEW map of Marketplace enrollees:
6.3 million live in Republican districts
5.2 million live in Democratic districts https://t.co/A1cBEoR0sj pic.twitter.com/W7x5FQ5w1i
— Cynthia Cox (@cynthiaccox) January 10, 2017
Odds are still extremely likely that the policy direction will be one that I don’t like but those odds have moved in the past month.
Well this is some very good news. So what the hell were Republicans doing when the House kept on voting on legislation to overturn the ACA? Wasting tax payer money, I guess.
They’re working on 2 plans:
Rub some dirt on it
Spray it with Windex, ho-kay.
Even if you believe in the legitimacy of evil policies, repeal and delay was cowardly malpractice.
You know what I havent heard talked a about yet is getting rid of the mandate, which was supposedly the most hated part of the ACA.
Here’s a question: I’m on the individual insurance market with one 22-year old son just out of college. My husband (he’s 13 years older than I am) turned 65 years ago and headed to the greener pastures of Medicare leaving us on our own as he was always the one whose job provided our coverage (including our son with pre-existing conditions). I stayed home and raised our kids. I’ve wondered if there are many families like mine and I was always hoping that there could be some kind of Medicare buy-in for dependents if a spouse turns 65. Have you ever heard of any kind of proposal like that? I know it’s not going to happen under this regime but I’m sure there are many (mostly) women out there in my position.
@Baud: there has been plenty of wonks talking about continuous enrollment policies as the effective replacement of the individual mandate
@Richard Mayhew: That would cause the number of insured to decline over time, no?
@Baud: getting rid of the mandate was a given in R plans: that’s why none of their plans add up in this universe. Should be ‘ ‘ around plans.
I think their way forward is to fiddle with funding to ‘failurize’ OCare, then dump everything/everyone under the rubric: government bad, market good, let’s go back to 2007 and GoFundMe medical plan.
But the only way to improve the ACA would be more plans, more affordability, more access to many more people, correct? How can Republicans do that after all these years of rhetoric.
Also, if replace is completely terrible I’m betting plenty of people will somehow blame Obama.
In other words, I am beyond pessimistic
Thanks for keeping us informed Mayhew.
They were spanking the monkey for the Tea Party. Turns out that’s not such great practice when one has to actually, uh, perform.
Is this sort of like what happenes when you put food in a barrel with a small hole and put it in a monkey cage?
@GregB: Um…And how would you know about that exactly?
They always wanted plausible deniability. Now they don’t have either.
Failure always must be blamed on someone else; even our Quisling press will not outright lie enough to let them dodge this particular responsibility. When it comes right down to killing their own voters and have their picture taken with the axe in their hand?
They are, fundamentally, cowards. We will do well to remember that.
The monkey reaches into the barrel and grabs the food, but it can’t pull the food out through the small hole because the hole is smaller than the clenched fist.
Now get your mind out of the Trump gutter.
Oh you starry-eyed optimist. I remember being like that, and then Bush v Gore.
**shrugs** Doesn’t matter. There are many people who just don’t like President Obama so them blaming him for hitting their big toe into a wall means nothing. If Republicans mess up the ACA, the blame will be all theirs.
@p.a.: Well, yes, they can always try. I just don’t think it will go over as well as it used to. The imposition of cynicism continues… the trust people had, pre-LBJ and Nixon, looks so quaint now.
I’ve been tweeting in the wilderness but I see no chance of repeal. Certainly not of real repeal–promises to repeal in 2019 or 2020 isn’t repeal and neither the press nor the Dems should let that categorization hold.
The only way out, given that the ACA has already got all the “stakeholder” “free market” “choice” elements in it, there is nothing much for the GOP to remove that doesn’t break the system, is to expand. I’m still betting on Trumpcare with a bigger Medicaid expansion that allows the Republican governors to take the money
@jayackroyd: There is a decent chance (15%+ IMO) that Replace is a technical corrections bill with shiny new ID cards and that is about it
I’ve been saying for a while now: “vouchers” is a Republican term for “take this piece of paper and pretend it works.”
Enhanced Voting Techniques
@Richard Mayhew: Well keep in mind the one and only true passion a GOP rep has is being reelected.
Remember that all they really care about is scraping the black part off. If they can turn the ACA into something that President Obama isn’t getting credit for, they’ll be perfectly happy with it.
Jack the Second
@eyelessgame: That’s certainly true of a subset of the Republican base, but there’s also a large group who thinks any government program that isn’t defense or law enforcement is immoral.
If we’re lucky these two groups can’t compromise enough to get anything done, but if they can and I had to bet on which got its way…
I’m old enough to remember when one of the GOP’s biggest complaints about Obama’s economic policies was that “American businesses need predictability so they can plan and run their operations, and Obama’s policies are completely unpredictable.” And yet, the idea of “we’ll figure it out as we go along” is actually being discussed. It isn’t very helpful for insurance companies, small businesses, and freelancers who rely on the ACA to not know WTF is going to happen to the insurance markets. Even big businesses will be affected since there are a ton of regulations applying to all insurance policies (pre-existing conditions, etc.). Perhaps the “predictability” rhetoric was purely not sincerely felt or thought through? I’d be positively shocked if that was true…
@eyelessgame: I disagree. The long game is to suck out our net worth and let us die.
@Enhanced Voting Techniques: That should be the only passion of a Dem politician too.
Instead of ‘repeal and replace’ or ‘repeal and hope’ I think the real GOP plan will be ‘wreck and blame’. They’ll make a mess, blame that mess on Obamacare, then repeal it once the mess is unmistakable. For the 2018 midterms they’ll be running as the guys who kept faith with their promise to clean up the mess that was Obamacare. Enough people will fall for it to allow them to keep their healthy majority.
I had a lean year last year income-wise, so I’ve now qualified for Medicaid. I just found out that my rent is probably going to go up by about 50% in two months. This is a bit scary.
I have a question. Why do there have to be Exchange Plans? Why can’t insurance companies let anyone buy the plans they offer to employers?
@Kitty: really good question and the basic answer is two fold:
1) The Exchange population is different than the large group employer market (much more transitory)
2) Provider contracts — providers sign on the dotted line for specific market segments. Individual is seen as a different market segment than group so providers need to sign new contracts. Highly unlikely that a carrier will have 100% identical network so things get tweaked.
And then there is also the question of regulation. ERISA is the controlling legal entity for self-insured group, states mostly control the regulation of fully insured group and it is a state/Fed split on the regulation of individual markets.
@Richard Mayhew: I see it as equal odds three ways. 1/3 technical corrections, 1/3 the crazies blow up the individual market by ending mandate and subsidies, 1/3 something like Price’s plan.
There’s a possibility that Republicans will alter O-care only enough to kill the Obama-cooties. But it won’t be easy for them– too many crazies want poor people (i.e., ‘losers’) dead.
West of the Cascades
I’m more optimistic after seeing that Senator Alexander released a proposal that sounds like … actual legislation (posted at Talkingpointsmemo – http://talkingpointsmemo.com/dc/key-gop-chair-unveils-most-detailed-plan-yet-to-repeal-and-replace-o-care).
Although I disagree with much of the proposal, it’s sort of nice to see a few actual adults still among the people governing the country. But I don’t believe that, collectively, the Republicans in Congress can do actual legislation … so an effort to actually pass a bill, that the few remaining Republican Senators actually interested in governing can probably get behind (get behind actually legislating, not necessarily agreeing on the details) is more likely pull apart any possible Republican agreement on how to proceed. Add in a President who is basically damaged goods upon arrival, and it becomes harder and harder for the Republicans to actually do anything.
@Richard Mayhew: Thanks!