Republicans are coalescing around what’s come to be known as the “repeal and delay” strategy for Obamacare.
By doing so, they’re revealing two key things. First, the party still doesn’t know what it wants the health care system to look like, even though it’s been over six years since the Affordable Care Act became law. Second, Republicans are willing to hold the entire health care industry and 22 million people hostage while they try to solve a riddle that has always eluded them.
Almost immediately after Donald Trump won the presidential election and the GOP held onto Congress, lawmakers recognized they faced a dilemma. After years of convincing voters that Obamacare is a policy disaster and that it tramples upon liberty, they believe they need to act swiftly on that front. But they also know they’ve never agreed among themselves, let alone with Democrats, on what should take the law’s place.
So they conceived a risky gambit. Pass repeal early next year, but leave the Obamacare system in place for a while ― three years, according to a new story in Politico ― so that the millions of people using the program can keep their insurance while Republicans craft an alternative.
It sounds great, but voting to end Obamacare, even years in the future, is likely to cause market problems right away. And that’s to say nothing of the anxiety that millions who depend on the health care provided through the Affordable Care Act will endure while they wait to find out exactly when they’re going to get kicked off their health insurance ― and what, if anything, they’ll get instead.
Republicans Think Repeal-And-Delay Is Good Politics
The political appeal that “repeal and delay” holds for Republicans is obvious. Come January, they will have the ability to undermine and effectively kill Obamacare on their own, by using the budget “reconciliation” process to eliminate the program’s funding. Reconciliation bills can get through the Senate with just 50 votes, which means Republicans would have one or two votes to spare, depending upon the outcome of an upcoming runoff election in Louisiana.
But a bill creating a new health insurance system would require changing government regulatory authority, among other things, and such a measure would likely have to pass through the regular legislative procedure. Democrats could stall debate indefinitely with a filibuster, and Republicans wouldn’t have the 60 votes to break it.
By taking Obamacare off the books now, with a fixed timetable for its end, Republicans figure they’ll force Democrats into a no-win situation. If Democrats end up blocking all GOP efforts at crafting a replacement, they will risk taking the blame for whatever chaos ensues. If some Democrats break ranks and agree to support GOP reforms, then they will give those changes bipartisan cover ―and share responsibility for whatever transformation ensues.
So far, Senate Democrats aren’t buying it, based on what they told Politico. And that’s not surprising. After spending eight years obstructing President Barack Obama’s agenda, sidelining congressional Democrats and refusing to take even the most basic steps to address the Affordable Care Act’s shortcomings, Republicans are expecting an awful lot from Democrats. The opposition party will be more inclined to let the GOP deal with its own mess while remaining unified against a president many, if not all, Democratic lawmakers believe is dangerous and unfit for office.
Even among Republicans, there’s dissent about “repeal and delay.”
Trump himself has expressed a preference for executing repeal and “replace” at the same time, although assigning meaning to any of Trump’s statements is a dubious proposition.
Sen. Lamar Alexander (R-Tenn.), who chairs the Health, Education, Labor and Pensions Committee, has been outspoken about the dangers of kicking the can down the road, and says he favors “replace and repeal” over “repeal and delay.”
There’s reason to share Alexander’s skepticism, as the recent history of using deadline “cliffs” to impel action on the debt ceiling and budget sequestration illustrates.
Republicans Still Can’t Decide How To Replace Obamacare
And then there’s the matter of the actual policy, and who gets to decide what it is.
House Speaker Paul Ryan (R-Wis.) has his “A Better Way” roadmap, but no legislation or official estimates of how his ideas would affect the number of people with health coverage, its cost or its budgetary implications.
And although Republicans are invigorated by their electoral triumph last month, the House GOP conference is fractious and includes a number of very conservative members who don’t want to do anything beyond repealing the Affordable Care Act.
The situation in the Senate is even less certain. Senate Majority Leader Mitch McConnell (R-Ky.) never even began a process of devising health care legislation so he and this committee chairmen practically will be starting from scratch.
And anyone who thinks the Senate will simply follow the House’s lead doesn’t understand the institutional rivalries between the two chambers of Congress.
Then there’s Trump. As a candidate, he at times promised universal health coverage, saying “everybody’s got to be covered.” Trump has also promised that whatever comes after Obamacare will provide “great health care for much less money.”
But after Election Day, he began adopting positions more in line with congressional Republicans on issues like cuts to Medicaid and Medicare. More recently, Trump announced that he intends to nominate Rep. Tom Price (R-Ga.) as secretary of Health and Human Services. Unlike Ryan and McConnell, Price has actually introduced legislation to “replace” the Affordable Care Act that diverges in key ways from Ryan’s policy prescriptions.
The common theme in all Republicans schemes, including the vague principles Trump formally endorsed, is that all would result in fewer people being covered, insurance that provides less financial protection for people with serious medical bills, or some combination of those factors.
There’s no reason to think this is what the public wants. On the contrary, a new poll shows just one-quarter of Americans support full repeal. Far more people support keeping Obamacare in place or strengthening it. And while the law on the whole has never been popular, its individual features (except for the controversial individual mandate) are ― particularly to the more than 20 million people now getting coverage through it.
So far Republicans have managed to avoid acknowledging the consequences of their scheme, which means they haven’t had to defend them to voters, interest groups, or dissenting members of their own caucuses. But the legislative process would force a reckoning and that’s going to make consensus hard to forge.
Delay Could Cause Serious New Problems In Obamacare Markets
“Repeal and delay” presents a more immediate problem. It assumes that Obamacare can keep going for three years, with that deadline looming. As many experts have pointed out, that’s unlikely. Many insurers selling policies in the law’s new marketplaces have been losing money, largely because enrollees turned out to be sicker on average ― and need more medical care ― than they had anticipated when they first set premiums.
A few insurers have pulled out of markets altogether. The rest have simply raised their premiums, figuring that the program would eventually stabilize and that building a customer base now would lead to profits later on. But insurers aren’t going to invest in a future market that’s not going to exist.
Health and Human Services Secretary Sylvia Burwell warned about precisely this problem in a recent interview, and she’s hardly the only one who thinks this way.
“Any significant delay between repeal of the ACA and clarity over what will replace it would likely lead insurers to exit the marketplaces in droves,” Larry Levitt, senior vice president of the Henry J. Kaiser Family Foundation, told The Huffington Post. “Insurers have been sticking it out for the promise of future profits, but if the future becomes uncertain, they’ll have little reason to stay in the market.”
Robert Laszewski, a health insurance consultant and frequent critic of Obamacare, told Vox’s Sarah Kliff that “Insurers have got to put their products together this spring, and we’re right in the middle of killing Obamacare. Are they going to submit proposals to sell in 2018? Why would they stay in the pool?”
Jon Kingsdale, a managing director at the Wakely consulting group, agrees that the timing could be critical. “The naturally conservative instincts of financial officers will be to cover the high end of their cost projections, and to exit the least profitable markets,” Kingsdale, who used to manage the Massachusetts insurance exchange, told HuffPost. “For large, publicly-traded insurers, the best strategy might be to exit Marketplaces altogether, so they can start afresh (or not) when the fog lifts.”
Insurers are likely to be particularly skittish because of the potential that Obamacare’s impending demise could make their risk pools worse. Basically, the people most likely to keep buying coverage amid uncertainty are the people who are most certain about their medical needs and most in need of coverage ― in other words, the people with the highest medical risks.
“It would be like a game of musical chairs,” Levitt said. “When the music stops, no insurer wants to be the only one left in the market with all of the sick people.”