Having waited years for the chance to repeal Obamacare, Republicans will finally have the opportunity in 2017. With the GOP controlling the White House, the Senate and the House of Representatives, the party can drive a stake through the Patient Protection and Affordable Care Act without a single Democratic vote — much as Democrats passed it in 2010 without a single Republican in support.
But repealing the ACA is one thing, improving the U.S. healthcare system quite another. The current GOP strategy will almost certainly make millions of Americans worse off than they are today, and even worse off than they were before the ACA (better known as “Obamacare”) was passed. Yet Republicans are so hell-bent to repeal one of President Obama’s signal achievements that they’re ignoring the catastrophe they could create.
The problem is the Republicans’ shoot-first, ask-questions-later approach. They tentatively plan to rush through a measure that would repeal key parts of the healthcare law, with an effective date two or three years in the future. Then they’ll work on a GOP version of healthcare reform to take its place, leaving consumers and insurers in a dangerous limbo in the meantime.
The immediate issue is the repeal-then-replace path Republicans are taking and the needless harm it could create.
Although that version remains to be seen, past GOP proposals would have done less to control rising healthcare costs than to revive the days of insurers cherry-picking customers and selling policies with gaping holes in coverage. But the immediate issue is the repeal-then-replace path Republicans are taking and the needless harm it could create.
The two-stage strategy helps Republicans overcome opposition by Senate Democrats, who have pledged to filibuster any effort to kill Obamacare. Here’s how it would work: Republicans would quickly push through a budget for the fiscal year that started almost three months ago — a measure that, by law, cannot be filibustered. It would instruct Congress to pass a budget ”reconciliation” bill — which also cannot be filibustered — to repeal Obamacare.
Doing so would plant a ticking time bomb under the subsidies in Obamacare that enabled roughly 20 million formerly uninsured people to gain coverage through Medicaid or private insurers. That sort of expansion is what many elected officials had been trying in vain to achieve before the ACA was approved. Republicans argue that they have a better approach to making insurance more accessible and affordable to those lower-income Americans — one that relies more heavily on tax credits and health savings accounts. To pass it without Democrats’ support, though, they’ll need another reconciliation bill in a future fiscal year.
That’s a pretty convoluted plan, and it has an enormous flaw because of the statutory limits on the reconciliation process. By law, reconciliation bills cannot include items that don’t have a direct effect on federal spending or revenue. And some of the most important provisions of the ACA (and any Republican alternative) are neither subsidies nor taxes — they’re insurance regulations designed to help people with preexisting conditions obtain coverage. In the ACA, these include the requirements that insurers offer policies to anyone who applies, that they stop basing premiums on an applicant’s medical history and that they no longer cancel policies after receiving large claims for medical care.
Some conservatives argue that those provisions are so tightly intertwined with the ACA’s subsidies and tax penalties, Congress will be able to repeal them through reconciliation as well. (Democrats have made a similar argument as they’ve defended various provisions of the ACA against court challenges.) But congressional Republicans explored that very issue late in 2015, when they crafted a reconciliation bill to repeal as much of the ACA as they could. (The measure was eventually vetoed by President Obama.) And they concluded that they could not touch the insurance reforms.
Besides, those regulations are strongly supported by consumers, even those who tell pollsters that they oppose Obamacare as a whole. But if they’re left in place without the tax penalties and premium subsidies of the ACA — particularly the requirement that virtually all adult Americans obtain health coverage — the regulations could send the market for individual insurance policies into a death spiral. Unless healthy people are pushed to buy insurance too, those who sign up for coverage will mainly be people who need costly treatment. That imbalance will force premiums up, making it even less likely that healthy people will enroll, driving premiums higher — or insurers out of the market.
Simply promising to fix that problem before the repeal takes effect won’t necessarily prevent chaos in the individual insurance market in the meantime. Three Brookings economists concluded in a recent report that this scenario would “very possibly” cause that market to collapse in some regions before a replacement bill could be designed. Insurers would either jack up premiums sharply or withdraw from the market in the face of uncertainty about enrollment and healthcare costs.
Nor is there any guarantee that Republicans could enact a new set of rules for insurers, given that they could not do so through a reconciliation bill. The GOP would have to bring Democrats on board to overcome a Senate filibuster. Republicans say Democrats wouldn’t dare block a replacement measure, but Democrats shouldn’t acquiesce to a bad GOP approach to healthcare just because Republicans decided to throw out Obamacare.
The individual insurance market is already strained in many states, thanks to the Republican obstinacy that has prevented Congress from addressing the shortcomings that have emerged in the Democrat-penned ACA. Rather than build on the solid foundation that the 2010 law created, Republicans in Congress and state governments did what they could to make it fail. The right approach now would be for lawmakers to fix Obamacare by addressing the factors that are causing premiums to escalate and competition to dwindle in the individual market. Unfortunately, it appears that Republicans are so determined simply to repeal the law, they’re going to make things worse in the short term with uncertain prospects at best for ever making them better over the long run.