What’s Actually Happening with the Affordable Care Act

Republicans officially began the process of repealing the Affordable Care Act this week. Key to note here is that it’s a process, not a one-shot deal. It is, however, a quickly moving process, since committees have been instructed to draw up legislation that would substantially dismantle the ACA by January 27th, just a week out from the inauguration. They appear to be sticking to their “repeal and delay” strategy (if you can call it a strategy rather than an irresponsible hey-let’s-see-what-happens-if-I-push-this-giant-red-button-and-then run-away scenario), which would cripple the ACA to such a degree that it would be highly ineffective at best and put millions of people’s healthcare at risk, while they hash out their plans to replace it.

What’s happened so far? The Republicans have begun the process of repealing the Affordable Care Act just as they did previously with a bill by none other than Health and Human Services appointee Tom Price. Using what’s known as the reconciliation process, which refers specifically to bills that have to do with budgetary matters, Republicans can repeal significant aspects of the ACA that would reverse all of the invaluable advances this country has made in healthcare with only a simple majority vote (51 out of 100 senators). Because they apparently have no shame — and this part is key and takes my breath away — the way for them to get around the fact that repealing the ACA will actually increase the deficit is to keep Medicare cuts that the ACA included since it covered those who benefited from Medicare with its other provisions. To meet budgetary rules and therefore be able to repeal the ACA with just 51 votes, they have to lower the deficit. That’s how they can do it: specifically by keeping Medicare cuts without providing any kind of safety net to Medicare beneficiaries, since so doing would raise the deficit. Technically speaking, Republicans wouldn’t fully repeal the ACA, but they’d dismantle it to such an extent that it would exist in name only. Unsurprisingly, Republicans don’t have a consensus replacement. If, however, Republicans can put together a bill over the first months of the year that meets budget rules, then they can repeal the ACA with a simple-majority vote. Republicans know how the process works: they did this before in 2015, and President Obama vetoed it.

Their 2015 effort at repealing the ACA is instructive in more ways than one. It’s entirely possible, for instance, for them to make their replacement bill sound reasonable and palatable, but in practice the new law would lack the necessary structure to deliver. Let’s take all the talk about keeping coverage for folks with preexisting conditions (party of one). Say they keep that legal structure and language in place, but then they scrap (as they want to do) the individual and employer mandates, the tax penalty for not signing up, and subsidies. It sounds like having your cake and eating it too, doesn’t it? But without the funding from the mandates, there’s no money to cover folks with preexisting conditions. You can’t have one without the other. The mandates exist specifically to balance the insurance marketplace, so if Republicans repeal them, everything else is just pretty words. The underlying premise of the Affordable Care Act was that of spreading cost. Younger and healthier people would sign up, which would help provide funding for medical care for sicker and older people — who previously could not get healthcare before at all, either because insurance companies felt they were too high-risk and so refused them coverage, or because insurance companies charged them unaffordable prices because of their high-risk status. Imagine telling that to young person with Crohn’s disease. Or a middle-aged person with Lupus. Or an elderly person with cancer. With the Affordable Care Act, everyone gets coverage who wants it and insurance companies can’t discriminate against people because of their age, gender, preexisting conditions, and so on. The system of course has problems that need to be worked out, but it has done incredible good for millions of American residents. Demolishing it will harm and even kill people, not help them.

In theory, insurance companies are supposed to provide reasonably priced coverage to all people without penalizing them because of their age, because they’re female, because they’re disabled, or because they have any chronic medical conditions. The 2015 law still had the language of the mandate because of the rules of the reconciliation process, so it could sound quite similar superficially. And it had the bonus of possibly sounding even better, because look! Not only will insurance companies not discriminate against you because you’re elderly, a woman, disabled, or already sick, but you also don’t have to pay extra taxes! But not really. As we face today, in practice there simply weren’t financial provisions to prevent insurance companies from charging the elderly, women, the disabled, the chronically ill forbidding prices, and effectively preventing them from receiving medically necessary healthcare. The current Republican plans include another caveat: if folks don’t maintain continuous coverage — say they lose their jobs that provided their healthcare, for example — then insurers can charge them more to purchase coverage if they have preexisting conditions. Watch not only what the Republicans say they’re doing, but what it actually means.

One of the potential replacements being floated is Paul Ryan’s Better Way plan. Here’s a basic idea of Ryan’s underlying philosophy as he explained it last year, which yours truly finds horrifically insulting:

“‘Less than 10 percent of people under 65 are what we call people with pre-existing conditions, who are really kind of uninsurable,” Ryan told a Georgetown University audience yesterday. “Let’s fund risk pools at the state level to subsidize their coverage, so that they can get affordable coverage. You dramatically lower the price for everybody else.’” (http://www.msnbc.com/rachel-maddow-show/paul-ryan-has-message-those-pre-existing-conditions)

One, that statistic isn’t true: 27% of non-elderly Americans have pre-existing illnesses. And two, I’m offended and appalled that, according to this statement, individuals with chronic health conditions are considered basically expendable. So much for being pro-life. While most replacement plans forbid insurance companies from refusing coverage to high-risk (read: the elderly, the chronically ill, the disabled) folks, they could charge them exponentially more because they’re older or sicker — which, in effect, would wind up meaning the same thing.

We need to make sure that Democratic representatives fully understand how vital the ACA is to millions of American residents. Of course it’s imperfect. Of course we need to figure out how to lower costs and improve efficacy of care. That’s always the battle. If anyone thought that we’d have a perfect healthcare law right away, well, I’ll just say that I’ve got a bridge in Brooklyn I’d like to sell you. Still, we need Democrats defending the law in unison and ensuring that their constituents know exactly what benefits the ACA has brought to them. We can’t just assume that they will do so. Because for the past months, many haven’t been. The ACA doesn’t work optimally unless enough healthy people sign up for coverage. Their premiums help balance the cost of covering the elderly and chronically ill. The major problem, as I see it, is less with the law itself and more with the fact that not enough healthy people have signed up, causing insurers to pull out of the marketplace. Relatedly, Democrats have not done a good enough job in publicizing the life-changing benefits of the law, as I discussed in my last piece. I remember when Obama first raised the ACA and having arguments with peers who said that they didn’t like the law because they didn’t need health insurance, so why should they pay? And then I explained that, number one, good health is not a guarantee at any age and so everyone should have health insurance, and number two, their money also went to help provide necessary care for the elderly and chronically ill. If we can keep the ACA, we can improve it in the future. If Republicans dismantle it, it’s anyone’s guess what will ultimately happen, but it will certainly be devastating to millions of Americans.

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