Obamacare is hovering on the edge of a legislative abyss. After over 60 futile votes by the House of Representatives to repeal or weaken the Affordable Care Act (ACA), only to run up against President Obama’s veto pen, the GOP is poised to gut the Democrats’ signature legislative accomplishment of the past eight years. Wednesday night, the Senate passed a budget resolution 51-48 that empowers Republicans to start picking the Affordable Care Act apart bit by legislative bit over the coming months. And short of staging demonstrations or trying to convince a handful of Republicans to learn to stop worrying and love the ACA, there’s not a thing Democrats can do to save the program that has already cost them so much.
However, Obamacare may well be as poisonous for the Republicans trying to scrap it as it was for the Democrats who passed and promoted it. Republicans’ rallying cry of “repeal and replace” is, and has always been, empty rhetoric. Simply put, the GOP has no credible plan to provide health insurance for a fraction of the 30 million Americans covered under the program they have pledged to repeal. Eager to repeal a program that clashes with their ideology but bereft of ideas to prevent a massive and sudden loss of coverage for millions of Americans, some Republicans have called for a more gradual phasing out (repeal and delay) of a program they had committed to scrapping on “day 1” before they comprehended what such a drastic disruption of the healthcare system would entail.
President-Elect Donald Trump, for his part, wants to see repeal and replace happen “very quickly or simultaneously, very shortly thereafter.” But the reality of a repeal, in the absence of a viable replacement plan (a few meager tax credits just don’t get the job done), is not so simple. In fact, it’s something of a political and policy nightmare. Now that repeal is an imminent reality rather than an aspiration, the GOP has no choice but to own the repercussions of a decision they committed to with their near-decade of demagoguery on the subject.
This should be little consolation to Democrats; for the GOP, repealing Obamacare is a matter of how and when, not if. Barring a dramatic reversal on the part of Republicans, Obamacare will die a death by a thousand legislative cuts. Republicans launched their opening salvo against the law by means of the budget reconciliation process, allowing them to bypass a Democratic filibuster. With the budget bill a reality in the Senate and likely to be passed in the House later this week, the GOP will have free reign to defund some key components of the ACA: insurance subsidies, the Medicaid expansion, the individual mandate, etc. Oh, and Planned Parenthood, just because they can.
Without the individual mandate, insurance companies are likely to pull out of the exchanges and/or raise premiums and deductibles to levels that ACA enrollees cannot afford. Ironically, the Obamacare death spiral that the GOP has promised would occur on its own will instead transpire as a result of their sabotage. Striking the individual mandate, Gary Claxton of the non-partisan Kaiser Family Foundation explains in the Washington Post, “would blow up the insurance market…the longer the period between repeal and replace is, the more the market unravels.”
Without the funding provided by the individual mandate and federal subsidies (some of which President Trump will eliminate with the stroke of a pen, others of which will fall victim to budget reconciliation), insurance companies may well be unable to provide coverage for individuals with pre-existing conditions, despite the GOP’s stated intention of keeping this popular part of the ACA. The marketplaces will be flooded with the old and the sick, while the young and the healthy opt for the short-term benefit of going uncovered (until the slings and arrows of outrageous fortune send them on an expensive trip to the ER). Meanwhile, ending the Medicaid expansion will leave millions of Americans just above the poverty line without health insurance and with no feasible way of obtaining it. Perhaps, without the minimum value standard set by the ACA, insurance companies will once again be free to sell “junk plans” that offer only catastrophic coverage.
Besides affecting insurance coverage for millions of Americans, repealing the ACA will have major structural implications for a healthcare system that has seen many changes under the complex, multi-faceted law. Tina Rosenberg explains in the New York Times: “The [Affordable Care Act] moves health care away from a fee-for-service model, which pays doctors and hospitals according to the number of procedures they do, toward value-based care, which pays based on what helps patients get better.”
Incentivizing value-based care, rather than encouraging healthcare providers to bill the federal government for expensive, often unnecessary procedures, has contributed to a slowing of the astronomical rise in healthcare expenditures. One would think such a result would please conservatives ostensibly dedicated to reducing spending. Alas, Republicans’ ideological aversion to Obamacare, a relatively small, market-based expansion of the social safety net, seems to outweigh their appreciation for structural benefits that align with their stated priorities.
Elections have consequences, and Democrats’ and progressives’ failure to defeat Trump has ensured that within months, Obamacare will be a terminally ill shadow of its former self, doomed to die a slow and painful death along with many of the people it once covered.
Given that the GOP controls both houses of Congress and the executive branch, Democrats are largely powerless to prevent repeal. They can, however, force Republicans to pay a steep political price for stripping 30 million Americans of health benefits. Indeed, it appears Democrats will attempt to do just that, banking on the likelihood that Americans will appreciate the ACA far more in the process of losing it than they did when its benefits were obscured by GOP propaganda—a result of a poor sales pitch on the part of its architects and the program’s inherent complexity. In essence, the Democrat’s strategy can be summed up as “blame Republicans.”
Senate Minority Leader Chuck Schumer, who not so long ago questioned the wisdom of the Obama administration’s prioritization of healthcare reform, insists: “They want to repeal it and then try to hang it on us. Not gonna happen. It’s their responsibility, plain and simple.”
Republicans have a remarkably similar strategy: blame Democrats. Vice President Elect Mike Pence recently pronounced from the right side of the aisle: “It’s important that we remind the American people of what they already know about Obamacare — that the promises that were made were all broken.”
Mike Pence’s statement is of course ludicrous, and Democrats should indeed call out Republicans who attempt to shift the blame for their legislative arson. But playing the blame game is not enough. Rather, the party’s progressive wing, hopefully with the support of a chastened establishment, must promote a positive vision for the future of healthcare in America. The GOP, lacking any coherent plan to replace the ACA, is essentially handing Democrats a blank slate. Progressives should seize the opportunity to sell their policy ideas—at the very least a public option, at best single-payer healthcare—to a receptive audience of Americans experiencing privatized healthcare at its hellish worst. Bernie Sanders proved in the Democratic primary that advocating Medicare for all was not political suicide; in fact, it was quite popular. Democrats should follow his lead and propose ambitious, progressive healthcare reform that does not derive from a blueprint provided by the Heritage Foundation in the 1990s.
The details of such a plan are beyond the scope of this article. However, it is imperative that progressives embrace a plan that does not leave the American people at the mercy of an insurance industry more interested in bottom lines than ensuring the best possible care for those who need it. The failure of the Obama administration to promote the ACA, a hybrid system that maintained private, employer-based healthcare, demonstrates that universal coverage is incompatible with the profit motive. It also shows that healthcare reform cannot be instituted or sustained from the top down.
The Tea Party’s success in rallying conservatives against “Obamacare” and other priorities shows that change, for the better or for the worst, must come from the bottom up. Democrats must accept that the ACA did not meet its demise exclusively due to the results of one election (although a Clinton victory would have ensured its survival and expansion). Rather, it represents a failure of the Democratic Party throughout the Obama years to make its case to the people, to generate grassroots enthusiasm for progressive legislation that is tremendously popular in content if not in name.
There is no way to spin the demise of the ACA as anything other than an unmitigated disaster. It could have served as a steppingstone to a public option had Democrats emerged victorious in 2016 with the party’s progressive wing ascendant. But there is no use dwelling on what might have been. It will take a tremendous, likely impossible, degree of political pressure on the part of the ACA’s defenders to save the law from the chopping block. But the end of Obamacare can mark the beginning of a monumental grassroots effort to advance more progressive healthcare reform.