After six years of conservative agitprop suggesting that the Affordable Care Act was failed or failing, even supporters of the landmark legislation are worried about its future. In part that is because of Obamacare’s current problems with keeping enough private insurance companies participating to make it possible for the exchanges to foster price and quality competition, and thus keep premiums for individual health polices affordable (there’s a separate problem involving the persistence of employer-sponsored health insurance, but its implications are down the road).
There are a variety of “fixes” available that could mitigate or even reverse the abandonment of Obamacare’s exchanges by private insurers: larger purchasing subsidies for people struggling to afford the new insurance; larger tax penalties for the younger and healthier folks who continue to go without insurance, which screws up the balance of the money going into and out of the system and threatens a “death spiral” of higher premiums for an ever-sicker population; and indirect subsidies for the insurers themselves that reduce their losses until the system has become a permanent part of the health-care landscape. Trouble is, of course, most of these “fixes” will require legislation, and unless Democrats pull off a trifecta in November and win control of both congressional chambers and the White House as well, Republican obstruction could make “fixes” impossible. In his usual understated way, President Obama himself in his recent interview with New York called a situation where “Congress just is not willing to make any constructive modifications” to the Affordable Care Act a “suboptimal solution.” That is indeed putting it mildly.
Indeed, accounts of the trajectory of Obamacare that treat the presidential election as a sort of an either-or (or perhaps neither-nor) moment for the health-reform initiative sometimes miss the point that Republicans may be able to maintain a veto over any Obamacare “fixes” even if they lose not only the White House but the Senate. In an important article over the weekend, the New York Times’ veteran health-care reporter Robert Pear accurately described the extreme and rapidly growing polarization in Congress between Democrats who believe a “public option” is urgently necessary to maintain the competitive viability of Obamacare exchanges, and Republicans who want to dismantle the entire edifice in favor of less government involvement, even if they cannot agree on an Obamacare replacement. It is this choice, Pear suggests, that is at stake on November 8.
That’s almost certainly true in terms of what will happen if Republicans win their own trifecta: the odds are very high that a Trump White House and a Republican-controlled Congress would quickly disable Obamacare via a budget-reconciliation bill that would kill subsidies or administrative appropriations for the ACA. A GOP Senate might also kill the use of the filibuster for regular legislation, which would make a full repeal of Obamacare entirely possible. And aside from the destruction Trump and congressional Republicans would inflict on the private-insurance exchanges that are one prong of Obamacare, they are also largely in agreement on the other prong, Medicaid. Far from being a vehicle for expanded health-insurance coverage, Medicaid would instead be turned into a block grant, letting the states to do health care for the poor or unhealthy what they’ve done for cash public assistance via welfare reform: largely abolishing it.
With each day that goes by, the odds of a mirror Democratic victory that flips the House become ever more remote. So it’s doubtful a President Clinton or a Senate Majority Leader Chuck Shumer would have the wherewithal to secure any Obamacare “fixes” that did not undermine the initiative’s entire purpose.
Yes, it’s possible that Republicans in that situation would pause at inviting blame for taking away health insurance for many millions of Americans, and in a majority of states, an expanded Medicaid would still be available to absorb the poorer and sicker people. But to be cynical about it, blame for bad things happening tends to affix to the party controlling the White House, especially in midterm elections, even if that is unjust in the extreme. So it could be a terrible mistake to assume that enough Republicans will automatically cooperate with a post-election Obamacare “fix” to make it anything more than a “suboptimal solution.”