I’ve been slowly moving towards only pessimism(75%) instead of certain(97%) that the ACA or something like is doomed.
I want to go over why my thinking is evolving.
My first piece of new evidence that changed my perspective is the retention of the filibuster. Part of that is to force the Democrats to the table in a Repeal and Replace cliff but also because it gave marginal Republican Senators a good bit of power and say over final final policy.
Two conservative wonks who actually know what they are talking about had a good Health Affairs article on the problems with Repeal and Delay:
An immediate repeal of the individual mandate’s penalty will lead some younger, healthier enrollees in ACA insurance plans to stop paying premiums. Even if the number of those dropping out in 2017 is small, it will be lead to further losses for insurers, and make it even more difficult for them to justify continued participation in 2018. There is a real danger that many parts of the country would be left with no insurance plans at all offering coverage on the ACA exchanges in 2018.
If Congress delays enacting a replacement plan, uncertainty about what might be in that legislation would further destabilize the exchange market even if ending the tax penalty for non-enrollment is tied to the ending of the premium credits and cost-sharing subsidies. Some number of current exchange enrollees, as well as insurers, are likely to view the coming termination of the ACA as a reason to withdraw their participation. Consumers may think they will eventually be spared any tax penalty even if they drop out of coverage, and insurers (and their shareholders) are likely to think it is unwise to make any kind of continued investment in a program that could soon disappear…..
But a plan that is focused on repeal without a clear vision for what will come next, or how it will be enacted, could easily backfire. There are numerous political, budgetary, and procedural obstacles to moving forward with an effective program to replace ACA.
To build a functioning marketplace, and to provide a ready path for all Americans to get health insurance, it is necessary to put together a coherent series of policies across Medicaid, employer-sponsored insurance, and the non-group insurance market. A workable plan will necessarily touch on all of these areas, and will be lengthy and politically contentious….
Jonathan Chait has been counting noses in the Republican Senate caucus:
Republicans need a House majority, 50 Senate votes, and soon-to-be President Trump to pass repeal and delay.
If Republicans lose three Senate votes, that drops them to 49, and repeal and delay cannot pass. At least three Republican senators (in addition to all the Democrats) now oppose repeal and delay. Rand Paul, of all people, has demanded that Congress repeal Obamacare at the same time it passes a plan to replace it. Paul has announced that he spoke with Trump and secured his agreement on this. Trump has not said so himself, confining his comments to date to a vague assurance, “That’s all gonna work out.”….
Even more ominously for the Republican leadership, four other Republicans have joined Corker to sponsor a bill delaying the bill that would repeal Obamacare for a month….
And then we get statements like the following:
Sen. Shelley Moore Capito (R-WV) tells me she wants an Obamacare replacement to cover MORE people than Obamacare. https://t.co/zEF4ORMfi3
— Sahil Kapur (@sahilkapur) January 9, 2017
The way Repeal and Replace was supposed to work was that a fait accompli would be delivered very early on with little dissension and the facts on the ground that the ACA was gone in twenty one months and Replace has to get passed with Democratic votes. We’re getting dissension. There is still a very good chance that something is going to pass as Repeal(ish) but the reality that healthcare is complex is becoming real to Republicans who actually have to look at policy results on their voters is moving me from the depth of despair to only pessimism.
— Cynthia Cox (@cynthiaccox) January 10, 2017
Odds are still extremely likely that the policy direction will be one that I don’t like but those odds have moved in the past month.