Republicans vs. Obamacare: GOP Has Backed Itself into a Corner

That means the ACA battle is going to get ugly, again.

Photo by Pete Souza

Most people who remember the original Obamacare scuffle, which happened way back in 2009–10, will tell you the fierce opposition was always more about ex-President Barack Obama than it was about ideological principles. For a variety of reasons—and I would not rank bigotry high on that list—the Republicans simply didn’t want President Obama to get credit for delivering on one of his biggest campaign promises.

Granted, there certainly were principled reasons for people to object to the Patient Protection and Affordable Care Act.

For conservative politicians, however, those reasons just weren’t dramatic enough to justify the rhetoric and persistence of the efforts to defeat the legislation. Prior to the hyper-politicizing of the issue, most Americans believed the United States government should provide access to meaningful health care for all citizens. Additionally, Obamacare is very similar to a GOP plan endorsed in 1993 by party heavyweights like Bob Dole, Orrin Hatch and Charles Grassley. It also bears a strong resemblance to Massachusetts’ so-called Romneycare, which was frequently applauded by the Heritage Foundation.

The plans are not identical so it made sense to fight against aspects of the ACA and even to vote against the final version. All the venom and repeated attempts to repeal legislation tens of millions of people wanted and reflecting fundamentals endorsed by true-blue conservatives, though? That was driven by personal and/or political vendettas.

At the time, the pettiness seemed like flirting with trouble and, sure enough, now the Republicans are neck-deep in it.

Obama is gone and Donald Trump, a nominal Republican, is President. Obamacare is teetering on the edge of collapse unless the GOP-controlled Congress temporarily extends cost-sharing subsidies and fixes the underlying financial mechanics, which are currently driving premiums up and leaving customers with fewer options as insurers leave exchanges. President Trump has pushed it closer to ruin by issuing an executive order that potentially weakens enforcement of the individual mandate, a critical measure necessary to defray the higher cost of insuring sicker customers (who presumably will enroll regardless of price and cannot be denied coverage).

In short, the ACA is in a death spiral and only the GOP can save it.

That might sound like a conservative dream come true after years of raging against the legislation, especially since repealing Obamacare was a central part of Trump’s victorious presidential campaign.

Ah, but there’s that line about the best laid plans of mice and men.

Unfortunately for Republicans, the Affordable Care Act has increased accessibility to coverage effectively via cost subsidies and equitable treatment of customers with preexisting conditions. Furthermore, this increased accessibility has proven to be popular across the political spectrum. The right-wing has acknowledged as much via promises to retain these facets and via early proposals for replacement legislation that provide financial assistance as well as protections for pre-existing conditions. Making matters worse, the Obama administration and Democrats have successfully made these two elements of increased accessibility synonymous with Obamacare.

That leaves Trump and the Republicans in the untenable position of having promised to repeal the ACA while simultaneously promising to retain the elements most closely associated with it.

Sounds like a neat trick under the best of circumstances.

Of course, the GOP trick will have to be even neater because Republicans have already taken material steps toward crippling Obamacare.

In order for the economics of the plan to work, the cost of the new, higher-risk (read: sicker) customers had to be offset by an influx of lower-risk (read: healthier) customers and spread across insurers. The individual mandate was meant to force healthy people to buy into the program or face a fine while insurers who made money via ACA exchanges would have to share those profits with insurers who lost money to smooth out the startup phase. Two vulnerabilities became obvious immediately i.e. a weak mandate that fails to channel enough healthy people into the program and a shortfall where the profitable insurers cannot make up the deficit of the unprofitable insurers.

Unsurprisingly, the Republicans zeroed right in on these weaknesses.

In addition to the aforementioned EO from Trump watering down the individual mandate, Marco Rubio and company have blocked availability of additional funds to mitigate costs to insurers during the early years of implementation. Whether you believe this was appropriate or not, it clearly reduced margins of error and squeezed the ACA’s precarious economics by limiting the pool of money available to compensate insurers who miscalculated premium rates in the face of expected uncertainty.

Consequently, President Trump and his colleagues will have to undo the damage they’ve already done while finding a workaround for the flaws that were inherent in the plan from its inception. They’ll need to do this while preserving the popular increased accessibility to health insurance, then they’ll need to convince voters the resulting legislation somehow honors the promises to repeal Obamacare or justifies the broken promises.

All with a major midterm election looming on the horizon.

Anyone out there see that happening gracefully?

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