The Coming Healthcare Battle Will Be Epic
24 Million People Could Lose Their Health Insurance. The Stakes Couldn’t Be Higher
President-elect Trump made a series of promises during his “victory tour” kickoff rally in Cincinnati. Among them was his familiar pledge to “repeal and replace Obamacare.” Trump is locked in and the battle over healthcare policy is set to return to the forefront of American politics.
The nomination of Georgia Representative Tom Price to lead HHS demonstrates that Trump, as Vox’s Sarah Kliff writes, is “absolutely serious about dismantling Obamacare.” Price has written one of the few fully fledged Republican alternatives to President Obama’s signature legislation. His plan, dubbed “Empowering Patients,” is premised around offering tax credits to uninsured Americans so they can purchase healthcare coverage on the private insurance market. The bill also repeals the ACA’s Medicaid expansion program that 15 million Americans have taken advantage of since 2014. As a consequence, most of these people would be forced to use Empowering Patients’ tax credits to purchase alternative coverage on the private market.
In lieu of the protections achieved through Obamacare’s Individual Mandate, Price’s bill promises to combat discrimination based on pre-existing medical conditions by giving insurers the freedom to jack up prices on customers that fail to maintain continuous coverage. Furthermore, the bill eliminates certain care requirements — making plans cheap for healthy people and expensive for the sick. A hypothetical example of the real-world consequences of this provision is illustrated in an example by Kliff: suppose a woman covered by a “healthy” PriceCare plan happens to get pregnant, if she is counting on her health insurance to cover the pregnancy, she would be “completely out of luck.”
Price’s plan, should President Trump decide to pursue it, would have to be passed by Congress. That brings up House Speaker Ryan’s own plans for healthcare entitlements. Ryan has long set his sights on privatizing Medicare. Now that Republicans are on the verge of controlling two branches of government, he’s finally in the position to make good on his goal.
Ryan’s plan for privatization would end the government-run Medicare program and replace it with vouchers from the federal government. The vouchers would be used to purchase (you guessed it) coverage on the private insurance market. The consequences for seniors are similar to the example of the young woman facing an unexpected pregnancy. Without the guarantees of Medicare, health insurance companies are free to design expensive plans targeting elderly patients that may not be able to pay for their coverage with Ryan’s “premium support” vouchers alone.
The enactment of these two plans would throw the post-Obamacare insurance market into chaos and cover far fewer people. Up to 24 million Americans could lose their current coverage and citizens 54 and younger will suddenly find themselves facing the fact that they’ll have to rely on private insurance alone instead of the option for Medicare in retirement.
While the battle over healthcare policy is always contentious, Medicare reform in particular has long been considered a third rail in politics. With their majorities in congress, its possible for Senate Republicans to overcome a Democratic filibuster through legislative maneuvers such as reconciliation. They will not, however, have the luxury to afford the defections of even a couple Republican senators. This is where public opinion plays an enormous role in deciding the fate of these programs.
Senators, unlike House members, represent the populations of their entire states. Senators in purple states will have to contend with the diverse nature of their constituencies. Even in deep red states like West Virginia, Senators are already feeling the pressure. West Virginia covers over 200,000 people under Obamacare’s Medicaid expansion. Republican Senator Shelley Moore Capito told Talking Points Memo, “I’m from a state that has an expanded Medicaid population that I am very concerned about.” She should be. As Democrats experienced over the past 8 years, healthcare bills can prove to be the most politically risky vote of a legislator’s career.
While most Americans agree that some changes should be made to federal healthcare entitlements to keep them sustainable, the overwhelming majority approve of the current programs. A survey by the Kaiser Foundation found that a staggering 77% of Americans (and 69% of Republicans) consider Medicare and Medicaid very important government programs. Even more consequential is the finding that 60% of Americans believe the programs are working well and 75% of patients currently on Medicare believe the same. The political risks of tampering with these deeply entrenched programs are self-evident. The Republican base tends to skew older and its voters are more likely to be current Medicare patients or will be soon. The danger of passing an unpopular plan could drain Trump’s political capital and cost Republicans dearly in the midterm elections.
As the possibility of repeal sinks in, there are signs that public opinion on Obamacare is shifting. An AP poll conducted between November 15–21 found that only 1 in 4 Americans want Obamacare fully repealed. There has also been a significant shift in Republican support as only 52% of Republicans want the law repealed now, down from 69% in October — a 17% shift against repeal since Donald Trump’s victory. Republicans leaders have indicated support for a “repeal and delay” strategy that would quickly repeal Obamacare before turning attention to crafting its replacement. This strategy presents an opportunity for Democrats to further erode support for Republican proposals and take the fight to the public.
Drawn out messaging battles while legislation is crafted tend to take a toll on the public’s support for controversial proposals. This especially true when healthcare is the issue at hand. The Tea Party blasted onto the political scene during the summer of 2009 when activists bombarded lawmakers at healthcare town halls across the country. They took an enormous toll on President Obama’s approval rating and made the law’s eventual passage even more difficult as spooked Democrats had to be wrangled back in line. The 2010 midterm elections would eventually cost Democrats 63 seats in the House and their majority.
The incoming Democratic Senate Minority Leader Chuck Schumer has telegraphed that the party intends to use Rep. Price’s nomination as an opportunity to paint the picture that “Republicans are plotting a war on seniors.” With the Democrats in the minority and Republicans now in charge of charting the direction of the country’s healthcare system, Dems have a simple and accurate message of contrast in their arsenal:
- Donald Trump and Paul Ryan want to end Medicare.
- Trump and Ryan plan to give seniors and the uninsured a coupon to fend for themselves on the private insurance market.
- Democrats want to protect and expand the entitlements you’ve earned.
The white working class voters that put Trump into the White House are disproportionately susceptible to losing their coverage due to an Obamacare repeal and if Democrats are successful in communicating the consequences, it could quickly put Trump’a party on the defensive.
In January 2005, fresh off his reelection and brimming with renewed political capital, George W. Bush pursued a plan to partially privatize Social Security. He confidently declared that he “earned capital in this campaign, political capital, and now I intend to spend it.” He traveled around the country to sell his plan. With Democrats unified in opposition, it soon became clear that “the more the President talked about Social Security, the more support for his plan declined.” By the summer of that year, the plan was dead and the defeat kicked off a chain of events that crippled Bush’s second term. He bungled Katrina, Iraq spiraled out of control, and the Democrats captured House. Two years later, Barack Obama won the White House and Democrats won a supermajority in Congress — a decisive repudiation of the Bush era.
History doesn’t repeat but it rhymes. It indicates that Republicans should tread very carefully around this powder keg of an issue. If they overplay their hands in defiance of public opinion and a united Democratic Party, they will find that tables can turn on a dime in Washington and political fortune can swiftly morph into devastating defeat.
