The Republican Party has used health care to its advantage for the last seven years by following the same strategy: advocating an alternative plan that does not and cannot exist. During this entire time, President Obama has held power. This has afforded them the luxury of posturing against the status quo — and, indeed, doing everything in their power, at both the federal and the state level, to make it worse. Republicans could denounce the messy negotiations in Congress, and then the messy reality of American health care, while promising that giving them power would let them start over and design a new reform that would protect everybody without having any objectionable features. After the election unexpectedly put them in full control of government, I predicted they would follow a “repeal and delay” plan, because it is the only way to keep the lie going. The closer they get to taking action, the more clear it becomes to Republicans that their own propaganda has trapped them and given them no escape. Railing against Obamacare was easy, but the responsibilities of power have taken all the fun out of denying medical care to the poor and sick.
From the standpoint of the most ideologically committed elements of the conservative base, destroying Obamacare was always the most salient pledge. Republican rhetoric treated the law as an existential threat to American freedom — the worst thing since slavery, as incoming Trump cabinet member Ben Carson put it. But from the standpoint of the electorate as a whole, the pledge to replace it with “something terrific,” as Trump put it, mattered just as much. A large number of Trump voters who get coverage through Obamacare “simply felt Trump couldn’t repeal a law that had done so much good for them,” reports Sarah Kliff, who spoke with many of them.
But any plan to replace Obamacare with something “terrific,” or even something almost as good as Obamacare, will violate conservative dogma. There’s no way around this. Despite the apparent complexity of the issue, it’s a very simple problem of resource allocation. In a free-market system, tens of millions of Americans will not be able to afford medical care because the cost of their treatment exceeds their income, either because they’re too poor, or because they’re too sick. A Kaiser Family Foundation analysis finds that 52 million Americans under the age of 65 have preexisting conditions that would make it impossible for them to purchase health insurance in the individual market that existed before Obamacare. An insurance-industry study from 2008 found that 13 percent of people who applied for coverage in the individual market were rejected — a figure that doesn’t even count the 34 percent of people who had to buy policies that excluded coverage of treatments for their preexisting conditions, let alone those who didn’t even bother applying because they knew they couldn’t afford it.
Covering people who can’t afford to pay for their own medical care means making other people pay for it. You can do that through direct tax-and-spend transfers, or through indirect regulatory methods (like making insurance companies overcharge healthy people and undercharge sick ones). Republicans oppose these methods because they oppose redistribution in general. And yet politics requires them to promise a plan that does not deprive Americans of access to treatment. This is the reason none of their plans has advanced beyond the white-paper concept phase —either they contain too much redistribution to be acceptable to the GOP, or too little coverage to be acceptable to the public, or both.
The health-care plans people like are ones such as Medicare, or employer-sponsored insurance — plans in which all customers pay the same rates regardless of age or preexisting conditions, and which don’t put them at risk of paying out huge costs if they get sick. Obamacare is less popular than those kinds of insurance because it has more market features. There’s more age discrimination, and higher deductibles designed to force consumers to be price-conscious. Republican health-care plans go much, much farther in this direction. They offer threadbare, catastrophic coverage with enormous deductibles. The English, vernacular term for the kind of insurance Republican health-care plans would offer is “crappy.” There is no world in which Republicans are going to give people “something terrific” or even close to it.
Some Republicans appear to have convinced themselves they can muddle through the dilemma somehow. Congressional staffers tell Philip Klein, a staunch Obamacare critic, that they plan to repeal the law quickly, and then replace it not all at once but with a series of “legislative changes that could be enacted in a series of shorter bills … for instance, one bill could theoretically be passed to address individuals with preexisting conditions.” This plan is so laughably hopeless it’s difficult to believe Republicans would attempt it. It’s impossible to gauge the impact of one change to the health-care system without knowing what other changes will be enacted. None of the stakeholders in the health-care system is going to support any discrete changes that could dramatically alter their business models without knowing what other changes may or may not follow.
Preexisting conditions are an obvious example of this problem. If insurers will be required to provide below-cost plans to people with expensive medical needs, they need to know what other measures will be put in place to compensate them: Subsidies? Regulations on healthy customers? Hospitals need to know how many uninsured patients they should expect to show up in their emergency rooms. In particular, popular parts of health-care reform (like benefits people get) need to be attached to unpopular parts (like ways to pay for it). You can’t address it in pieces. During the debate in Congress over health-care reform, Republicans ginned up a talking point about how reform should be done in small steps, but no serious person of any ideological perspective would construct a reform by passing a bunch of bills one at a time, without knowing whether the next bill will pass.
Blowing up Obamacare, and then bringing up a series of small bills in the hope that they add up to something decent is not a strategy. It’s what Homer Simpson came up with when he faced a test he knew he couldn’t pass. (“I’ve been working on a plan. During the exam, I’ll hide under some coats, and hope that somehow everything will work out.”)
Even some very conservative Republicans, who have spent years denouncing Obamacare as a socialist monstrosity, have acknowledged the political impossibility of throwing 20 million people off their insurance. If Republicans blow up Obamacare, “the media and the left will blame the repeal vote for any turmoil in insurance markets,” editorializes The Wall Street Journal, “Republicans will own health care, like it or not.” John Goodman, a conservative health-care-policy activist, concedes, “It’s not going to be politically possible to throw 20 million people out on the street without health insurance.”
Repeal-and-delay is the ultimate backhand acknowledgement that the party has no answers. Their wan hope is that by repealing the law, they can satisfy the blood lust of conservative activists. The repeal won’t take place for years. Then they can hide under some coats and hope it all works out.
But even this step has proven extremely tricky. If Republicans repeal Obamacare without creating a replacement, insurers will have little reason to stay in the marketplace. They’ll start canceling plans immediately, and the news will be filled with stories of Americans being thrown off their medication and, in some very real cases, dying. Repeal-and-delay will actually require taking additional action to prevent a meltdown. Insurers have begun negotiating behind-the-scenes with Republicans in Congress for concessions that would allow them to continue to cover their existing customers. Hospitals are also warning Republicans that blowing the system up without a replacement would expose them to massive financial risk. Obamacare financed its coverage expansion in part by reducing payments to hospitals that have to treat uninsured customers who show up at the emergency room, on the grounds that there would be fewer of them. If Republicans create millions more uninsured people, they’ll start showing up in emergency rooms, and the hospitals will be on the hook.
Republicans can certainly patch up the exchanges and keep them going during a transition period. All it would require is halting their relentless efforts to blow up the law and start trying to make it work. (“They want to pump money back in to the insurers without appearing like they’re giving them a handout or bailing them out,” one insurance lobbyist explains.) But if they do this, then they’ll have essentially proven that they can fix Obamacare. And if they can fix it, why would they let it expire? Especially when the deadline for the replacement approaches and, inevitably, Republicans have still failed to produce a replacement?
The most likely answer is that Republicans never craft a replacement. They repeal Obamacare, but delay the effective date of the repeal, and then Obamacare becomes a “cliff” that Congress votes to keep extending. There is no majority in Congress behind any one specific plan to replace Obamacare, but there is probably a majority against blowing it up immediately. That will likely become the new status quo. There’s no transition to a new plan. The transition is the plan. Or, at least, it will be.
Sahil Kapur reports that Republicans in Congress are contemplating a transition period that could last as long as four years. It is obviously ludicrous to rush to repeal the law while delaying the effective date of the repeal for four years. Arch-conservatives in Congress are already lobbying to move up the repeal date for this reason — but even if they succeed in phasing out Obamacare over two or three years rather than four, it just means that Congress will have to pass another extension. The most likely outcome is that Republicans keep extending the law until Democrats have the presidency again, at which point they’ll no longer have an incentive to prevent mass suffering, and can go back to opposing anything Democrats try to do to make the system work. Republicans just need to keep the system from collapsing on their watch.
If Republicans truly believed Obamacare creates more victims than beneficiaries, they would blow it up immediately. And if they really had an alternative that was more popular, they would wait to write it before they eliminated it. Repeal-and-delay proves that neither one of these is true. They have no better plan. All they can do is promise some better plan lies over a horizon that will never arrive.