JOHN GEYMAN FOR BUZZFLASH AT TRUTHOUT
Republicans in Congress and the Trump administration have boxed themselves into a corner on health care. Whatever they do, they will be blamed for inevitable increases in costs of health care, growing instability of health care markets, and escalating public backlash over their policies or lack thereof.
President Trump and congressional Republicans are not on the same page. Trump has found health care to be more complicated than he ever imagined, revealing his ignorance of the issues, but keeps pressuring Congress to pass a repeal and replace the ACA on an urgent basis, with little awareness of what that might entail. As he tries to assure us that the GOP’s resulting “plan” will bring access to care to everyone, at lower cost, and be “amazing,” Republicans in the Senate are coming to grips with what to do with the narrowly passed House bill, the American Health Care Act (AHCA), which after receiving it, they vowed to start again from scratch.
Republicans have four basic choices at this point, none of them good:
1. Repeal the ACA without a replacement plan;
2. Pass their own modified AHCA, retaining some of the most popular provisions of the ACA;
3. Actively sabotage the ACA administratively while trying to blame its demise on Democrats; or
4. Do nothing, let the ACA collapse on its own while trying to deny any responsibility for it.
These options, of course, are not entirely mutually exclusive, but none of them will resolve either the GOP’s problems or address the needs of Americans.
Let’s look at each of these approaches in terms of their political risks to the party now controlling both the White House and Congress, which for the last seven years has waged war against the ACA (Obamacare).
Option 1 is completely untenable, since it would expose the GOP for having no plan of its own after all these years, and show how incompetent it is in trying to pull together a plan. It would also fuel a growing backlash as the ACA becomes more popular and up to 24 million Americans lose health insurance.
Option 2 is, as an understatement, problematic. Whether the Senate can pass a bill that will also clear the House is a major question. Within the Senate, these are some of the tough issues that will have to be dealt with in its bill:
• What ACA provisions should be kept, such as keeping children on parents’ policies until age 26?
• What to do with cost sharing reduction (CSR) payments (subsidies or tax credits) that were opposed by the GOP for years? The insurance industry lobbies for their continuation, but they are still in limbo as the Trump administration has just delayed a decision for another 90 days.
• How much latitude should insurers be given about reducing their coverage of the ACA’s ten essential benefits?
• What cuts will be made in coverage of women’s health care?
• Should work requirements be made as a condition of coverage?
• What provisions should be made for states that expanded Medicaid under the ACA?
• To what extent can insurers charge older Americans higher premiums? (The AHCA allows a 5:1 difference, but states could request a waiver to charge older enrollees even higher than for younger enrollees).
• To what extent should the government protect insurers from their claimed losses through such mechanisms as risk corridors and re-insurance?
• Under what circumstances can insurers deny coverage for pre-existing conditions?
3. Option 3 is already underway, as illustrated by the recent announcement by the White House that enrollment for small business plans will no longer be available on Health-care.gov that the Administration is no longer enforcing the ACA’s individual mandate to buy coverage, and that CMS will now accept shorter sign-up periods that work against the needs of many potential enrollees.
4. Option 4 may well happen if the GOP is successful in sufficiently undermining the ACA, which will likely lead to marked hikes in insurance premiums for 2018, further roiling of the insurance marketplace, and exits of more insurers from the market. In that event, a recent poll by the Kaiser Family Foundation found that a majority of Americans will blame the Republicans, not the Democrats.
Regardless of how these options, or combinations thereof, play out in coming months, Republicans will own the damage whatever they do. The resulting chaos will be obvious to all that their supposed principles—such as more efficiency, affordable premiums and deductibles, more value for less cost, offering more real choices for all Americans, and less bureaucracy—are outright lies.
The House bill for the AHCA has already encountered strong opposition from many quarters, including from insurers that fear a collapsing marketplace with fewer enrollees and the loss of subsidies, from hospitals that will lose revenues from fewer paying patients as the numbers of uninsured grow, from seniors who face higher premiums and deductibles, from women who fear higher costs and loss of women’s reproductive rights, from safety net facilities, and most importantly, from the many millions more Americans who will become uninsured or increasingly underinsured as insurers offer ever more skimpy “insurance.” Aetna, the country’s third largest insurer, has already left all of its ACA exchanges as its CEO calls the industry in a “death spiral.”
Anthem, one of the largest insurers, threatens to exit its markets if government subsidies are stopped. Some markets are likely to have just one remaining insurer, while there may be no coverage available in some rural areas, such as in parts of Iowa and Tennessee.
Thus, as they respond to their base, Republicans and the Trump administration are facing political suicide no matter what they do. The furor in Town Halls across the country over health care is likely to test moderate Republicans facing re-election in 2018. The shift of just four Republican senators to the Democrats’ united opposition to a modified AHCA will defeat it in the Senate.
As this debate grinds on, both Democrats defending an unsustainable ACA that has failed to contain health care costs, and Republicans who want to repeal it without a credible replacement plan, will lose out on the obvious third alternative in plain sight—to support single-payer Medicare for All (the Conyers bill in the House, H. R. 676), which already has 112 co-sponsors. It remains to be seen whether Democrats and more moderate Republicans will grasp this opportunity. Meanwhile, as the stakes rise with no other serious alternative on the horizon, support for single-payer is approaching the boiling point. As RoseAnn DeMoro, executive director of National Nurses United, recently observed:
If ever there were a need for bipartisan problem solving with real solutions, this could and should be the moment, given the high stakes for all Americans. This can become a game-changer in the 2018 and 2020 election cycles.
Adapted in part from my 2017 book, Crisis in U.S. Health Care: Corporate Power vs. the Common Good and the recently released pamphlet, "Common Sense about Health Care Reform in America." Visit: http://www.johngeymanmd.org