So now what?

So now what?

That is a hell of a question but I think the right way to start probing towards some of boundaries of the possibility space is to ask what happened.

As I see it, the winning coalition that blocked the bill was a combination of unanimous Democratic opposition plus state level Republicans who actually have to balance a state budget and deal with real issues plus Republicans in districts that make them inherently vulnerable during a mid-term swing against the incumbent party plus the reactionaries of the House Freedom Caucus. We were also aided by the ineptitude of the wank “wonk” Paul Ryan and his coterie of enablers.

We told our stories. We mobilized. We stiffened the spine of Democrats whose spines probably did not need much stiffening. We put the fear of god into vulnerable Republicans. We scared the people who have to balance a state budget. We had on our side almost all of the interest groups that had bought into the ACA — doctors, insurers, hospitals, big drug makers and everyone else that gave a bit to get a bit. The only people who were not aghast at the AHCA were high income tax cut fanatics and policy illiterate decision makers.

We had a huge and unusual coalition pushing back against a bum’s rush. Most of this coalition was assembled in 2009 and 2010 to push the ACA through. And it was re-activated days after the election as everyone recovered from their shock, dismay and hangovers. Any time something changed, wonks were ripping through the documenation and making fast, rough and directionally right analysis with maps, figures, graphs and other hooks to allow advocates to tell personal, powerful stories that landed. And we kept on iterating powerful and emotionally connecting truth on every iteration of the bill.

We won. And our win helps our community:

Does it mean I finally can breathe again? That my health care won’t be pulled in a matter of weeks or months, on the eve of my starting biologic therapy for my Crohn’s?

This is why we fight. We’re not going to win every time. But we have to fight for conceding defeat and defeatism without making an effort means throwing ArchTeryx and others to the dogs. We’re not going to win every time, but we need to fight for both the chance to win as we did this week and to be able to look at our friends, our countrymen and ourselves with honesty as we say that we are doing everything that we can. We will need that for immigration. We will need that for global warming. We need that for our LBG and especially T allies. We might not win every time, but we can mitigate some damage, impose some delay, inflict some cost, and build effective coalitions for future action and progress every time that we hold to our values and our ideals.

So what does this mean for policy? The fear is that the ACA is here, but that the Trump Administration will sabotage it. This is a real fear, and it is one that the coalition that won this week will need to be engaged on to protect the implementation of the ACA.

There is only one completely destructive threat. The cost sharing reduction (CSR) subsidies are in limbo. They were paid for March but they could disappear at any time due to a re-interpretation of HHS legal guidance. If they go, the exchanges go as insurers are allowed to run and they will run if they are forced to pick up another 20% of actuarial value without compensation. It is a guaranteed money loser. There should be two objectives. First, a single page bill to transform CSR from discretionary to mandatory spending should be filed as the price of any Democratic support for a continuing resolution or debt ceiling increase. Secondly, every ACA-defending wonk and advocate needs to be screaming loud and clear that the CSR decision is completely a discretionary Republican decision to sabotage the Exchanges.

Essential Health Benefits and contraception coverage are vulnerable to rule making. They can be trimmed or cost-sharing free contraception may be eliminated but the lawyers can tie up decision making for quite a while.

Non-enforcement of the mandate should be priced into the premiums that insurers submit this spring. It will be pain that is borne by the non-subsidized buyers but subsidized buyers are protected. Insurers should also assume there will be no advertising campaign by Healthcare.gov and price appropriately as well as fund advertising. Ads work.

Really bad Medicaid waivers will be approved. Bad ones should be fought. But at the same time, if a Trump Administration approving an Indiana like waiver is what it takes for Florida, Georgia, North Carolina, Texas or any other hold-out state from expanding, the net good of a bad expansion easily, in my moral universe, outweighs the benefits of holding out for a no strings attached expansion in 2021 or later.

We will need to fight and be aware of sabotage but the ACA is structurally hard to knock down with the exception of the CSR risk.






27 replies
  1. 1
    OzarkHillbilly says:

    Always another battle to be fought.

  2. 2
    PaulW says:

    any way for the insurance companies to slap the trumpites if they try to mess with the CSR?

  3. 3
    Waspuppet says:

    Secondly, every ACA-defending wonk and advocate needs to be screaming loud and clear that the CSR decision is completely a discretionary Republican decision to sabotage the Exchanges.

    “They couldn’t beat the ACA in a fair, open Congress, so now they’re trying to kill it in a back room with no voters watching.”

    My faith in Democrats’ ability to stick to talking points is limited, but that seems like a good one.

  4. 4
    JPL says:

    Tom Price will do his utmost to make sure, that health care law is weakened.

    BTW early voting starts today, for Price’s seat. The polling station that I normally early vote at is closed this year for the district 6 vote early vote. Instead they are opening a polling station convenient to Handel’s supporters. There is a city council runoff the same day as the district 6 election. I can early vote for the city council election starting the 10th of April at the normal early voting site, but not district 6. The location that is open, you can do both starting the tenth, which conveniently is where the person running for council that the mayor wants, lives. My mayor thinks Ossoff’s name sounds funny, have you heard. Sorry to rant, but something doesn’t smell right.

  5. 5
    MattF says:

    And if Trump offers Democrats a ‘deal’? Get it in public, in writing, engraved in stone on Mount Rushmore. Then, just… maybe… demand more.

  6. 6
    mai naem mobile says:

    @MattF: I don’t trust Dolt 45 as far as you can throw his ass and I don’t trust McConnell as far as you can throw his ass. There should be very very limited to no cooperation with the GOP.

  7. 7
    jayboat says:

    Any time something changed, wonks were ripping through the documenation and making fast, rough and directionally right analysis with maps, figures, graphs and other hooks to allow advocates to tell personal, powerful stories that landed. And we kept on iterating powerful and emotionally connecting truth on every iteration of the bill.

    This. This is the new age we live in and it gives me hope-
    where information (knowledge) is still power,
    and availability and management of same has some hi-tech wrinkles.

    Use and manipulation of info can lead to good or bad. (see Putin, V., Guccifer 2.0)
    Rooting for injuries and hoping the blowback from dolt45
    will be a tsunami of new, energized and engaged young voters.

    The argument could be made that it’s a variation of the same thing the Russians did-
    info manipulation and highly focused strategy and use of resources
    but without the lies, cheating and deception.

    The groundswell of activism and energy is heartening to see.

  8. 8

    @jayboat: This is where I had value.

  9. 9
    Cermet says:

    If holding the continuing resolution

    to transform CSR from discretionary to mandatory spending

    is done by the dems, they can still be beaten by the thugs who really control both houses; however, such a stance will prove that the dems have backbones and that the thugs own the ACA’s rise in insurance rates. There is hoping … .

  10. 10
    rikyrah says:

    Thanks Mayhew. I was wondering about this myself.

  11. 11
    randy khan says:

    And, let’s not forget, we have other issues to fight on, too, starting with Neil Gorsuch.

  12. 12
    wuzzat says:

    You know, it might not be a bad idea for the Democrats to pay for some “Schoolhouse Rock”-style ads between now and 2018 explaining things like “Cutting federal assistance programs means yours too” and “Going to the ER for free makes everyone’s healthcare costs go up” and “Now that sexism is over, can tampons be FSA-eligible, pretty please?”

  13. 13
    Buskertype says:

    Thanks for this breakdown of the threats.
    It looks like there’s some progress on state Medicaid expansion… Maine has a ballot initiative and Kansas (!) looks like it might want a slice of the pie.

  14. 14
    sheila in nc says:

    @David Anderson: Yes! Yes, you did! And I’m just about to send your CSR post to my congresscritter, the estimable and extremely blue David Price, unless he is yours also and you have already enlightened him?

  15. 15
    ding7777 says:

    In those counties where there is only a single profitable insurer it might be better for that insurer to stay (at least for 1 month) and sue the Trump administration for non-payment

  16. 16
    O. Felix Culpa says:

    From Indivisible, a useful summary of the legislative process, Schoolhouse Rock being a dim memory and all.

  17. 17
    the Conster, la Citoyenne says:

    Thanks so much David – this info is exactly what I was looking for. Ignored in all the millions of words about the politics of the ACA the last few days is any substantive discussion at all from any panelists/pundits/talking heads is what provision of the ACA creates sub-optimal results, and how to fix it. Armed with this information, we can now demand that our Congresspeople keep CSR on their radar as a leverage point. Another talking point trotted out over and over by Republicans is that there isn’t enough competition by insurers for rural communities, and that their premiums have gone up so much – which they overdramatize as Obamacare’s implosion – granted, probably because Medicaid hasn’t been expanded there because of their own Republican state legislators, but, is there another mechanism in the current law that can be used to reverse that trend?

  18. 18
    Spanky says:

    @OzarkHillbilly:

    Always another battle to be fought.

    A good definition of life itself. But really, how many times are our battles so clearly defined? ‘Tis a luxury.

  19. 19
    suzula says:

    “First, a single page bill to transform CSR from discretionary to mandatory spending should be filed as the price of any Democratic support for a continuing resolution or debt ceiling increase. Secondly, every ACA-defending wonk and advocate needs to be screaming loud and clear that the CSR decision is completely a discretionary Republican decision to sabotage the Exchanges.”

    How do we make sure these happen?

  20. 20
    ding7777 says:

    Do you have link to where/when the CSRs are paid ? Is April 1 the next payment date?

  21. 21
    MomSense says:

    Thought I would share this article about our Medicaid expansion referendum question.

    It has qualified for the ballot and organizing is starting in earnest.

    This would be a BFD for us here in Maine where the horrors of falling into the Medicaid Gap are real and terrible.

    Medicaid expansion headed to voters.

  22. 22
    jonothan8 says:

    As an America-loving New Zealander and long-time Juice reader who stared slack-jawed at the rise of Trump like much of the rest of the world, might I say how great it’s been seeing the way so many Americans – and American institutions – reared up and said “fuck no!” from the day of the inauguration – versus the supine way the Remain camp in the UK just lay down in the face of the Brexit disaster.

  23. 23
    Tarragon says:

    This is interesting. My family’s PCP is leaving at the end of the month and my wife just found out where he’s going. He’s moving in to something involving Medicaid accountability. Her summary is that he’s going to be working to insure patients are getting the correct care under Medicaid.

    That still leave a lot of possibilities open but he’s a smart guy and knows his way around insurance so this could be a really good thing. You know except that we need to find a new PCP after a lot of years, but good on a larger scale.

  24. 24

    Good posting, but, if I may, this is not the place to use the imagery of the “bum’s rush”. The bum’s rush is when you grab a person by the neck of their shirt, and their belt (or the back of their pants) and bend them over until their center of mass is below their hips. You may now give them the “bum’s rush” – pitching them out of your establishment; their feet can get no purchase so you can throw them, face first, out the door. It’s also called the “old heave ho” for obvious reasons.

    It’s also time for the Democrats to propose a raft of technical fixes to prevent abuse by the insurance companies, and ensure affordability of insurance by employers and individuals.

  25. 25
    David in NY says:

    I don’t understand. I thought the CSR subsidies were baked into the statute, at least in broad enough ways that would defeat failing to fund them. Can you explain what part of the subsidies is statutory (and that the administration couldn’t change) and what part is subject to administrative change? Thanks.

  26. 26
    David in NY says:

    And how will we know as soon as they try to undermine the subsidies? I think that could well be a loser for them, with just enough publicity.

  27. 27

    […] how exactly Trump and Tom Price might go about sabotaging the ACA through the executive branch, David Anderson at Balloon Juice has you covered. The next battle will be fought for the cost sharing reduction […]

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