The messy politics of repealing the ACA
(Bloomberg View) — Donald Trump and Republicans are about to encounter a political nightmare: unraveling the Affordable Care Act.
Already there are tensions between Trump, who's been shaky on the specifics of the 2010 healthcare law and says he wants to keep the popular parts, and congressional leaders like House Speaker Paul Ryan and conservative think tanks who ideologically, almost theologically, oppose anything associated with the Affordable Care Act.
They're going to get squeezed in a political vise. The Republican base demands that the ACA be repealed, but most voters have more nuanced ideas. Polls consistently show that while a plurality of voters disapproves of the law, big majorities want to keep some provisions and care more about issues like rising drug prices.
While candidate Trump vowed to repeal the law, he also said he'd like to see Medicare negotiate lower drug prices and bring in cheaper drugs from Canada, positions fiercely opposed by most congressional Republicans and the drug industry. The president-elect now says he wants to keep important elements of Obamacare, including a ban on insurance companies discriminating against people with preexisting medical conditions and another allowing kids to stay on their parents' plans until age 26.
There's a reason Republicans have voted to repeal Obamacare scores of times but have not in six-and-a-half years devised a coherent replacement: it's tough substantively, and treacherous politically.
An example of self-deception: Two conservative analysts wrote in Politico last week that an exit poll showed that 47% of voters think the act went too far and only 18% thought it about right. "That gives Republicans a mandate to pass legislation to repeal and replace the law as soon as possible next year," wrote the analysts, Brian Blase of the Mercatus Center at George Mason University and Paul Winfree of the Heritage Foundation.
What they forgot to cite is that 31% of respondents to the same survey thought the law "did not go far enough."
The conservative replacement plans do not envision going further. Even the part on preexisting conditions would be weakened.
What Republicans, probably with Trump on board, want to do is defund a big chunk of the ACA early in the budget process next year. Then they would come back later to complete the repeal and replacement.
The best policy and politics would be to fix parts of the law that have produced big recent increases in the cost of premiums for the sliver of Americans who don't get insurance through Medicare, Medicaid or their employers, and don't qualify for subsidies through Obamacare. Some cutbacks and additional cost controls would also be useful and popular. But the Republican base would never accept those measures, meaning the likely course will be to craft a radical replacement.
Then, a year or two from now, the headlines wouldn't be about rising premiums or not being able to keep your own doctor. They'd be about some of the 20 million newly insured people being thrown off the rolls; cutbacks in Medicaid for poorer Americans; crowded emergency rooms; weakening of provisions that are reducing hospital-caused patient harms; maybe some hospitals going broke, and the insurance industry in chaos. If Ryan gets his way there could also be articles about steps toward privatizing Medicare despite Trump's campaign pledge not to. (The Speaker was called out for falsely claiming last week that this course was needed because Obamacare is causing Medicare to go "broke." In reality, the full solvency of the hospital part of Medicare has been extended for up to 12 years.)
That picture would not sit well with a lot of the working-class voters who backed Trump.
It would be one of the many lessons inflicted upon the new president. Going back to the early 1990s, the politics of health care has repeatedly changed. Democrat Bill Clinton was elected president by promising to reform the system -- "It's about the economy, stupid, and don't forget health care" was his campaign mantra. His plan proved unpopular and failed, giving Republicans a boost on their way to taking control of the House of Representatives in 1994. The next pendulum swing helped President Barack Obama get elected in 2000, only to see the result become a successful issue for Republicans.
Now it's their turn to feel the heat again.
This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.