Thursday, December 8, 2016

The Deal On Repeal

Greg Sargent looks at the dilemma facing GOP senators over Obamacare repeal.

Some of the states with the highest populations of people getting subsidies are represented by GOP Senators. This includes Florida (more than 1.4 million); Texas (more than 913,000); North Carolina (more than 499,000); Georgia (more than 427,000); and Pennsylvania (more than 321,000). Many other states with GOP senators also have sizable populations getting subsidies. 
Keep in mind, this doesn’t even include the Medicaid expansion. By my calculations, more than 20 GOP senators represent states that have expanded Medicaid. (The ones that have expanded Medicaid and have one or two GOP Senators are Alabama, Alaska, Arizona, Arkansas, Colorado, Indiana, Iowa, Kentucky, Louisiana, Montana, Nevada, North Dakota, Ohio, Pennsylvania, and West Virginia.) Many of those are red states. 
Now, in fairness, Republicans keep insisting they are going to replace the ACA in ways that minimize the disruptions for all these people. And it’s true that some of the GOP replace plans — such as the one offered by Trump’s pick for health and human services secretary, GOP Rep. Tom Price — offer their own subsidy schemes. But those plans tend to use criteria different from income level to determine eligibility for subsidies, and there is little indication that anywhere near as many people would get them. Republicans have also talked about keeping some form of the Medicaid expansion money while block-granting control to the states. But it’s unclear whether Republicans can unite behind any replace plan including all of these things in any case.

Right now, Republicans appear to be coalescing behind a strategy that would repeal the ACA but delay repeal’s implementation for a few years, to give Republicans time to work out a consensus replacement. But given that so many people might be left without coverage if they don’t, the question becomes: How many Republicans will vote for repeal if no replace plan has been determined yet? 
One GOP Senator, Susan Collins of Maine, is now saying she may not support repeal unless there is some replacement ready to go. There is no telling what she will actually do in the end. But it’s possible that this could indicate other GOP senators may grow increasingly uncomfortable with supporting repeal-and-maybe-never-replace. There are other problems with this strategy, too. With no certainty about what’s next, insurers might exit the market. Alternatively, if Republicans do keep the ban on discrimination against people with preexisting conditions (as they say they want to do; after all, it’s popular) while repealing the individual mandate, that could make the insurance pool a lot sicker and lead to a dreaded “death spiral.”

On paper this is where things get very, very bad for the GOP.  A repeal followed by "well we'll come up with something in 2019" plan is going to kill them in the states they need to win in, and they know it.  So how do they pull it off?

Meanwhile, conservative writer Philip Klein asks a good question: Why would it be any easier for Republicans to pass a replace plan heading into the next presidential election? If anything, it would probably be harder. 
The thinking among Republicans seems to be that, with a deadline looming for millions to lose health coverage, Democrats can be pressured into helping support a replace plan that is much more in keeping with GOP priorities, which is to say, it will spend and regulate far less, and cover far fewer people (while allowing them to say they have health care solutions). But as Brian Beutler notes, if anything, Democrats might be able to use this to leverage Republicans. After all, a sizable block of conservative Republicans may be resistant to passing anything that spends a lot of money to cover people. If so, Republicans would only be able to pass something with the help of a sizable chunk of Democrats, which could presumably give them a way to pressure into Republicans for a plan that’s somewhat more to Democrats’ liking.

So we're counting on a unified front under Chuck Schumer.

Of course, for all these reasons, it’s possible no replacement will ever materialize. Republicans might be fine with that outcome. I used to think that Republicans might pay a big price for yanking coverage out from under millions. I’m no longer sure. But if no replacement does materialize, it is true that we will be looking at a very big mess, heading right into the 2020 elections — including in a lot of red and swing states — and there’s no telling how that will play.

We know how this will play: it'll be Obama's fault and Republicans won't pay a price for it at all. It's worked for eight years.  There's no reason to believe it won't continue to work, at least for the next two. But hey, the Urban Institute finds that the GOP repeal plan will wreck the insurance markets badly enough to leave thirty million uninsured.

I'm sure they'll just blame Obama.

They'll get away with it too.

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