Repeal and Replace Becomes Repair and Rename: On Replacing ObamaCare with the Affordable Care Act

Following the election that swept both Donald Trump and the current Republican Congress into power, there has been much chatter about repealing the Affordable Care Act, often termed ObamaCare.The Republicans have considered it a top governing priority since the moment the Affordable Care Act passed, and have campaigned in several midterm and presidential elections on opposing it, with a remarkable consistency. Now that they have the reins in Washington, it is high time for them to “put their money where their mouth is”, for the “disaster known as ObamaCare” as President Trump has often termed it, to be laid to rest.

Republicans in Congress are quickly learning that this is easier said than done. Firstly, the law’s repeal requires congressional majorities to the degree that the GOP does not have, but this first barrier has found a reply in the process known as reconciliation, an obscure budgetary process whereby relevant committees in the House select government programs to cut so as to balance the government’s budget.

Great! Problem solved, right? Time for Paul Ryan and Mitch McConnell to take a well earned break, then?

Wrong.

Two main problems arise from this, and will highlight the largely preferable policy tack of, instead of going forward with this repeal plan, to work on legislating around the law’s existing issues - a policy that would find increased support from congressional Democrats and the American public than their current plans.

The first issue is that taking healthcare away from over twenty million Americans does not, on the overall, poll well in very many districts. Concern for reelection prospects, especially for those senators up for reelection in the 2018 midterm elections, are salient.

Signs of early concern, many of them mirroring that seen surrounding the 2010 midterm elections for Democrats, at which time the major debate was that of enacting ObamaCare. Just as Tea Party Republicans attended Democratic town halls en masse in 2010, nowadays YouTube and Facebook have been rife with videos of constituents protesting their congresspeople, from Senator Chuck Grassley being given a packet of Tums and being told he’ll need it, to deafening yells answering a Florida congressman’s claim of death panels. Senator Marco Rubio derided town hall attendees as “rude and stupid”, saying he wouldn’t meet with his Florida constituents at all.

There are, in this sense, clear signs for worry, and polling backs that up: a recent CNN poll had ObamaCare support at an all-time high, and a Kaiser Family Foundation poll finds 65% support for the law’s expansions of Medicaid to millions of low-income Americans. For Republicans to, as they have often previously indicated, go forward with repealing of many of these widely popular provisions, such as the oft-cited plan to replace Medicaid expansion with vouchers and high-risk insurance pools (where sicklier people are covered by subsidized health insurance exchanges so as to lower policies for the healthy).

The second issue, which is highly correlated with the first, comes in the second half of the GOP’s go-to line on ObamaCare for the past few years: the “replace” in “repeal and replace”. There are several ObamaCare replacement plans, but three stand out most prominently: the Cassidy-Collins Plan in the Senate, Health and Human Services Secretary Tom Price’s unnamed bill on the subject, and the broad strokes plan outlined by Speaker of the House Paul Ryan.

The Cassidy-Collins Plan, designed by Senators Bill Cassidy of Louisiana and Susan Collins of Maine and outlined in their Patient Freedom Act, has earned praise from liberal commentators for its pledge to allow states that like ObamaCare healthcare exchanges to keep them.

“California and New York, you like ObamaCare, you should keep it.” Senator Cassidy was quoted as saying at the press conference detailing the Act. “It’s not for us to dictate. [...] Now you can say to a blue-state senator who is invested in supporting ObamaCare, ‘you can keep it, but why force it on us?’” This version of events is overly simplistic, and ignores the fact that the Cassidy-Collins Plan’s provisions would provide three essential choices for states: (1) to keep ObamaCare as is (under the assumption that markets would remain unchanged by surrounding states’ abandonment of the policy), (2) to remove all federal provisions to return to the pre-ObamaCare lack of any coverage expansions, or (3) toswitch to an auto-enrollment provision that mandates health insurance for all uninsured residents, who would then be placed into a federally subsidized catastrophic plan.

Current HHS Secretary and former congressman for Georgia’s 6th congressional district, Tom Price, had the most fleshed out legislative plan for ObamaCare repeal coming into the 2016 election cycle. His Empowering Patients First Act had already been voted on in the House of Representatives and the Senate, having been vetoed by President Obama already.

His plan works to benefit young people, healthy people, and higher-income people, who Price views as being disproportionately affected by the ACA, with many of the law’s policies emerging in a kind of response to this perceived excess payment by these groups for their counterparts: specifically old people, sick people (especially those with pre-existing conditions), and lower-income Americans.

The plan loosens ACA restrictions on discrimination against those seeking individual health plans while being afflicted with a pre-existing condition by allowing their discrimination if their coverage isn’t continuous, sets a $3 billion subsidy over three years for its high-risk pool plans (despite the Congressional Budget Office’s recommendation for a $170 billion subsidy over a longer timescale), and allows young people to get simpler catastrophic plans so as to attract more of them to health exchanges.

Lastly, the plan popularized by Speaker Ryan and House Republicans, as originally outlined in his “Better Way” talking points and recently leaked plans on House Republicans’ thus-incomplete actual ObamaCare repeal bill, largely follows the same tune as Secretary Price’s plans in terms of high risk insurance pools and in allowing discrimination in non-continuous coverage, but reduces the penalty for the latter. It again echoes Price on catastrophic plans, but allows states to define the ways in which this would be settled. The bill, through this emphasis on younger people, presents a situation within which many states could decide to shape their plans in such a way that older Americans could easily end up financially excluded from some exchanges.

The plan has a strong, Ryan-esque focus on tax credits bracketed, not by income but by age, to avoid this issue with older Americans by balancing out their potential financial issues as more young people enter the market, and giving all American taxpayers more of an opportunity to purchase health insurance through these tax credits. This plan led to a popular criticism that, as voiced by Last Week Tonight’s John Oliver, that Bill Gates would be given the largest tax credit on this plan, with his $83 billion net worth doing nothing to disqualify him from it, and that a young person working for minimum wage would have the smallest.

All of these proposals have been estimated to dramatically raise federal healthcare spending in comparison to other nations, not to mention the United States as it currently stands with ObamaCare provisions, along with a projected rise in the uninsured rate, to varying effects, but widely considered large by agreeing on eliminating Medicaid expansions in many or all states.

Now, none of these plans have consolidated support in the Republican Party, and none can expect any tangible measure of Democratic support in the House and Senate.

Republicans campaigned on tackling the issues of ObamaCare with their replacements, but thus far these issues are not remedied by any of the plans that have any significant measure of popularity in the GOP caucus in either house of Congress.

They campaigned on battling increasing healthcare costs, something that none of these plans address – in fact, they all allow for further pricing liberty that will allow these companies to raise prices extensively on healthcare plans and medication.

They campaigned on eliminating unnecessary healthcare taxation, but effective expenditures for most families, with the exception of those among the highest income and wealth percentiles, will instead rise.

They campaigned on helping those who fall through the cracks of insurance and are, in their eyes, unduly punished by the individual mandate, but they offer no tangible solution towards lowering the uninsured rate.

The GOP campaigned on cutting the cost of ObamaCare to federal and state governments, but this offers to a sharp rhetorical contrast to the fact that covering the cost of life-saving treatment for those who cannot afford it is the principal reason Americans have higher healthcare spending per capita than any other industrialized nation in the world, and these plans do not address this situation.

Even President Obama himself has said that he will personally endorse any plan that improves upon his law’s failures.

Republicans, now caught between a rock and a hard place, must attempt to find a solution where they can repeal the ACA, and replace it with a better law that still adheres to their small government philosophy. Already, voices from the party’s right wing have argued they will not vote for any replacement law, such as several lawmakers from the GOP Freedom Caucus have, and seek only to eliminate President Obama’s healthcare reforms once and for all.

The path towards repeal and replace, therefore, is extremely fraught.

But what, then,  is the best way to repeal and replace ObamaCare?

Here’s an idea: to not do so at all.

The government costs in ObamaCare are often agreed-upon as an issue. The lack of young people in insurance markets have been an issue in Democratic and Republican circles alike. Restricting discrimination for the uninsured and keeping young people on their parents’ plans until age 26 are pointsof widespread agreement.

Republicans would certainly find their goals of saving on government expenditure to be widely correlated with the proven concordance with Medicaid expansion and the proven drop in US government spending per capita on healthcare. Working across the aisle with Democrats and with different factions within their own caucus would follow the trend shown in past Congresses, who focused on large-scale reform and improvement of wide-spanning and influential laws, in a manner that is relatively bipartisan.

President George W. Bush’s work on the expansion of Medicaid Part D is a relevant example in this case. The sense of impermanence and focus on repeal from the opposing party runs contrary to the common functions of American government when working on major legislation. Republican voices were clearly and purposefully absent from negotiations on the Affordable Care Act, with Leaders McConnell & Boehner explicitly seeking to cast the Democratic majority as working alone to pass the law.

Those very same Republican voices are important now, more than ever, when they finally have the power to effect change. This is a power they must not seek to abuse. They must look to set aside political incentives towards working on tax cuts, and work on fixing the largest problems with the Affordable Care Act in a bipartisan manner, in this way achieving the actual improvements in government expenditure, individual savings and freedom, and healthcare efficiency that they have campaigned on fixing.

They would certainly find political reward in this new and improved healthcare system, with actual policy improvements in people’s lives to boot.