Republican efforts to reveal Obamacare share one devastating fault. They all result in the loss of health insurance for around 20 million or more Americans. The latest legislative effort under Republican leadership, the Graham-Cassidy plan, threatens to dramatically curtail federal funding to Medicaid and result in, at least, 21 million Americans going without health insurance. Although Republicans are using opposition to Obamacare as a means to garner support among their base, twenty million is a big number that could represent a big voting block capable of undermining Republican chances on a national level. Even if all 20 million were not compelled to lash out against Republicans, the number of those who would is enough to stir strong emotions among Democrats and moderates.
The greatest defense of the Affordable Care Act, i.e. Obamacare, was never the Obama Administration’s constant defense of the legislation, Democratic control of the Federal government, or any of its successes. In fact, Democrats hurt themselves by defending the shortcomings of the legislation. Doing so rallied Republican supporters to repeal Obamacare and discouraged Democratic support who could not rally around a tainted healthcare reform effort with limited successes. Today, Republicans face similar backlash, because they lack a better option. The greatest defense of Obamacare comes from framing repeal as the loss of health coverage. To save themselves from this booby trap, Republicans must either give up on repeal or work with Democrats to further healthcare reform efforts.
Republican efforts, thus far, have been designed to accomplish Republican priorities that they know Democrats will never support. Absent landslide elections favoring Republicans in 2018 and 2020, which require an energized Republican voter base and a subdued Democratic voter base, which is unlikely in the wake of the Donald Trump Presidency, procedural maneuvering is their only hope. The opportunity to utilize the reconciliation budget measure to sneak in changes to ACA with a simple majority will be lost at the end of September. Republicans will, then, have to rely on Democratic support to pass an Obamcare repeal or alternative healthcare reform until another opportunity allows them to circumvent Democratic input.
The risk to Republicans is straightforward. Not only could this be one of their last chances to repeal Obamacare and implement their own policy prioritizes over future Democratic changes, it could cost the GOP votes for years and further stir rebellion in its ranks. Democrats, however, risk miscalculating Republican chances. Just as Donald Trump was elected over Hillary Clinton, Democrats could easily become the less appealing choice due to their stances on other issues. In the meantime, Donald Trump can use his Executive Powers to undermine Obamacare. With more than three years to go in Office, Trump can do a lot of damage. There is, of course, the damage the stalemate will do to the American People, the US healthcare system, and the US economy. All sides, therefore, have a reason to cooperate.
The most unpopular aspect of Obamacare, which guaranteed the viability of the private insurance market, was the individual mandate. If lawmakers are serious about healthcare reform, Democrats and Republicans could be united to immediately remove the individual mandate with a clean bill addressing just that issue. With that in mind, the Congressional Budget Office seems to believe the repeal of the individual mandate would result in 16 million American electing to go without health insurance. Although this 16 million alone has doomed Republican efforts, a CBO score featuring such a figure would become irrelevant in the face of bipartisan legislation and the repeal of the individual mandate. By focusing on the individual mandate, healthcare reform will no longer be framed as an issue of people losing insurance. It will become an issue of personal choice versus taxes and penalizing people who cannot afford insurance.
With the repeal of the individual mandate, Obamacare would become more vulnerable to repeal. The Affordable Care Acts’ prohibition against the use of preconditions would, however, take center stage and the debate would shift back to access to care, which encompasses the issues of affordability and availability. Republicans cannot win a debate that frames healthcare reform as an effort to take away the insurance of people who have preconditions to guarantee the profits of private insurance companies. Few will fight for free health insurance for the poor, which will result in efforts to eradicate Medicaid instead of finding a way to achieve universal coverage, but the lack of an individual mandate will force the private insurance market to support a public option.
Required to provide coverage for those who have preconditions, without raising premiums, and unable to force healthy people to buy health insurance, the health insurance industry will have to undertake dramatic changes to survive. As the health insurance industry already dumps the most costly Americans onto government roles, i.e. Medicare, Medicaid, etc, it will be forced to expand on its current efforts to provide less for more profit without looking like the bad guy. They may well come to support Bernie Sanders’ Medicaid for All. At the very least, they will eventually come to see a public option allows taxpayers to share the burden of the American People’s healthcare and creates a new opportunity for them to underwrite government plans and provide lower risk supplemental health insurance for those who are dissatisfied with the public option.
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