Despite brave and bullying promises from Republicans to repeal the health reform "monstrosity" this past week, they can't do it. Not in the next two years, and maybe not even in 2012, no matter who wins the presidency. Why? For now, because even if the Senate agreed with the House and passed a repeal bill, President Obama would veto it. By 2012 the growing number of Americans (more than half) who already like provisions of the new law, will want to keep them.
If not repeal then, what about death by a thousand cuts? Most policy analysts believe that there are several provisions of the law that could well be revised or starved, if not outright repealed. Most of those provisions will mean little to the American public (e.g. the Independent Payment Advisory Board (IPAB), the Center for Innovation in Medicare, the Patient Outcomes Research Institute (PCORI), the 1099 reporting requirements), but at least the first three are key to cost control in the long run. The much debated individual mandate, requiring everyone to have insurance, is making its way through the courts and could well end up in the Supreme Court, where the outcome is unknown. Republicans have vowed to have hearings every week next year, many of which will focus on the health reform law. The goal of those hearings is to stab health reform in its heart over and over again, and advocates for health reform can only hope that Americans are too busy trying to survive to listen to C-SPAN.
There are at least four groups of Americans who will gain a lot from health reform and who should push back on repeal or revision - 1) Those who can't buy any insurance because they are or have been sick 2) Those who can't afford insurance even if they are well, 3) Those who are employed but would love to leave their job but are afraid of losing their insurance, and 4) Those whose livelihoods depend on getting paid for providing care (i.e. doctors, nurses, hospitals, pharmaceutical companies, etc.) The latter category is a huge constituency for most of the basic aspects of the health reform law, since the burden of the uninsured on hospitals and doctors is becoming unsustainable. Even the health insurer constituency supports aspects of health reform like the individual mandate, since if everyone is "in", the healthy can subsidize the sick in a reasonable way.
The most important question to ask now is: What would the Republicans propose IF they could repeal health reform? Unfortunately, their answers are as old as the debate itself. There is absolutely nothing new in the pledges to America of Reps. Cantor and Boehner. They make the same old talking points they have been making for 20 years: 1) Selling insurance across state lines; 2) malpractice reform; and 3) more personal responsibility for health care. These solutions sound innocuous but they will not solve either the crisis of the uninsured or the need to bring costs down. John Goodman has made some good points about the value of selling insurance across state lines, but his argument relies primarily on a public that is willing to pay less to get less, and then not whine when they get sick and want more! Selling insurance across state lines means that insurance companies will base themselves in states that have little regulation and few mandates to cover things like maternity care or even emergency services. Malpractice reform has been shown over and over again to contribute less than 2% to the costs of health care, so while it is a good idea, it is not "the" answer to the most pressing health reform issues. And more personal responsibility usually translates into high deductible plans that requires the member to spend $2500 or more out of their pocket before any serious coverage kicks in. These "consumer driven" plans, as they are called, are much the same as the high deductible plans that many Americans currently hold, although occasionally they cover doctor visits with a co-pay. They are based on the theory that buying medical care is like buying a car or a refrigerator, which of course it is not. Despite Republican attacks on health reform, at least ten of the main ideas in the Affordable Care Act have previously been proposed by Republicans, according to the Center for American Progress.
What should we watch for in the next year or so? Regular hearings by Congress which will require key Administration officials to spend time preparing for and defending health reform; symbolic gestures like bills that have no chance of passage but will appear like "progress" for those that oppose health reform; provisions that take away the money (or try to) from the implementation of full reform in 2014; and countless provisions of the law attached to other bills like defense that make them hard to vote down. Symbolic politics is just that. It is symbolic not action. It does not solve problems. It makes Washington politicians "look" like they are solving problems. But in the end, Americans and their families who are not lucky enough to be completely healthy with jobs and health insurance, will struggle to get coverage and keep it. Buyer beware, you say? Voters already rejected that idea. But if you voted differently, you need to pay attention to what is about to happen and help your friends and families understand the real purpose of these activities. It will be more important than ever to keep refuting the lies and misrepresentations of health reform.