These have been lonely years to be a supporter of the Affordable Care Act (ACA), in the face of sustained attacks from its enemies and neglect from its friends. I find dark humor now reading about plans to replace the ACA. For example, when I read, “lawmakers are working to forge a consensus on what form the ACA replacement will take” I hear, “congress has no clue how to pull this off.” Then there are those poor souls I have read about who are celebrating Obamacare’s repeal but hope they can keep the insurance they received through the ACA.
Democrats have suddenly found religion and are defending the law, claiming that repeal will bring catastrophe. Repeal alone would bring catastrophe, but that won’t happen. Lawmakers are smart enough to avoid ACA repeal doomsday scenarios that would hurt them in the next election. Repeal will bring many negative effects, but the replacement, whatever form it takes will mean it won’t unfold the way many ACA supporters think. I foresee a disaster unfolding more slowly, where many healthy people and people with means will be less affected. They may even benefit..in the short term.
ACA supporters focusing on people losing health insurance when the ACA is repealed are forgetting something critical. The number of uninsured matters only when we all agree on what it means to have health insurance. And that agreement is about to unravel. Defining health insurance as a set of broad and deep benefits was something the ACA did. Without emphasizing that the ACA provided critical definitions for what being insured meant, ACA defenders are setting themselves up for failure when these definitions are destroyed upon repeal. The non partisan Congressional Budget Office (CBO) recognized the concern about counting people with cut-rate plans as “insured:”
The CBO is providing an important safeguard, but only by reminding lawmakers what is in the ACA. Lawmakers are doing their best to circumvent the CBO. Anticipate that repeal will dismantle the definitions of what being insured means, because dramatically loosening the definition is how to lower costs and maintain “coverage” at the same time, i.e. by slight of hand.
The dramatic decrease in the number of uninsured under the ACA was a spectacular achievement because the insurance they received was of high quality. Once the ACA is repealed, this number will become less meaningful. Supporters of the law have doomed themselves with this one dimensional focus. After repeal, maintaining the number of insured people will be simple: sell everyone health insurance for $10 a month that covers band-aids and crutches. This is how coverage will be “solved.”
ACA supporters are wrong to predict immediate catastrophe because lawmakers will “repeal” the ACA with a built in multi-year delay to cover their asses. The delay will allow lawmakers to grab headlines and peacock their way around the talk shows, all the while spinelessly protecting themselves from immediate catastrophe. They repealed Obamacare and the sky didn’t fall!! Nothing will actually have happened yet. Lawmakers can and will say, “look, we repealed Obamacare, and no one lost their insurance like the scaremongers said!” Yeah, right. Not yet.
Ironically, another way the GOP is protecting people from losing their ACA-provided healthcare right away is by spending billions of dollars on the ACA that months ago they were dead set against. The time bomb will go off eventually. The hand wavy lip service to the magical effects ACA repeal will have is just that, and the only way congress will be able to lower costs and avoid a huge drop in the number of insured will be by defined payments or vouchers. If lawmakers give everyone in the US a coupon for $1000 for their health insurance (it will be more complicated than that, but) they can say, a) we gave everyone insurance! So much better than ACA!! and b) we did it with so much less money!! Look at the cost savings of our genius!! I am bracing myself for the fact that this will be seen as a good thing by many healthy Americans. It will be a problem at first mostly for the sick.
Focusing the pain on people with disease is part of the plan. Another way that cheaper insurance will become available for most people is with “high risk pools.” Which is a nice way of breaking the social contract of taking care of the sick among us. If we separate the healthy from the sick when dealing with healthcare insurance, then the healthy people will pay less. Lawmakers will put aside money for high risk people likely with defined contributions, i.e. a set amount. Only with time will it be revealed that in order to save money, voucher/defined contribution plans will be catastrophically insufficient for people with modest incomes who get sick.
I have one last prediction directed at thoughtful critics of the ACA like @avik and @mfcannon who earnestly believe, based on their free market principles, that ACA repeal will bring wonderful results: the lousy situation after ACA repeal won’t shake their beliefs. When costs go up, when sick people receive worse care, when job creation stalls, the free market folks will have a simple explanation: “sure, I said we should repeal the ACA..but not like *that!*” Their well-intentioned arguments will have been used as a smoke screen for political ends.
The repeal effort may yet stall, but I doubt it. Affordable Care Act RIP. It was ungainly and unloved. It should have been improved, not removed in a game of political football. The law wasn’t magic but nothing is, and it was clear to nonpartisan observers that it worked surprisingly well while it lasted. Now, patients and those that care for them need to prepare for what’s coming next.