And so it begins. After six years of posturing and futile votes to repeal the Affordable Care Act, Republicans in the Senate have started a process to erase the most important provisions of the health reform law with a simple majority. Millions of Americans are at risk of losing their coverage.
Republican opponents of the health care law insist that it has failed, though it has reduced the number of uninsured Americans to the lowest level in history. They say that it has driven up costs, though health care costs have risen at a much slower pace since 2010 than they did in years past. And opponents promise they will somehow make health care cheaper and more readily available, though after all these years of reviling Obamacare they have yet to offer any serious alternative. The reality is that the repeal-at-all-costs crowd is ideologically opposed to any government role in the health care system, though every other advanced economy in the world has embraced some form of government intervention as the only way to manage costs and ensure universal access.
With a narrow 52-48 majority in the Senate, Republicans are seeking to evade a Democratic filibuster by instructing congressional committees to draft a budget reconciliation bill to effectively repeal the tax and spending provisions of the ACA, gutting the law and increasing the deficit. The House is expected to easily pass a repeal of the ACA, since it has already done so dozens of times.
It should perhaps come as no surprise that zealots would resort to using a budgetary maneuver to fundamentally change national policy. But it is still galling, especially because the Republicans have put forward no coherent plan for what would replace the ACA. To cope with that rather glaring omission, leaders like House Speaker Paul Ryan and Vice President-elect Mike Pence have discussed repealing the law but then delaying its end — claiming political victory while leaving President Barack Obama’s plan largely in place — to give Congress and the Trump administration more time to come up with a replacement.
This is cynical politics, of course, but it is also dangerously irresponsible governance. Most experts and much of the health industry — including trade associations representing insurers, hospitals and doctors — have warned that repealing the law without an adequate substitute could be disastrous. Health insurers that see no long-term future for the law will have little incentive to keep offering plans that it would support. And the health insurance marketplaces set up by the ACA will collapse in much of the country if Republicans repeal the individual mandate to purchase health insurance and get rid of or scale back the subsidies available to help people buy policies.
Obama and congressional Democrats met Wednesday to discuss how best to protect the ACA. They might start by making the case that Obama has never quite managed to make for the benefits of the law and the dangers of repeal. In particular, they might highlight the stories of the millions of people who voted for Donald Trump and congressional Republicans and now stand to lose their health insurance.
A recent Urban Institute study estimated that 956,000 people in Pennsylvania and 1 million each in Georgia and North Carolina could lose coverage under a repeal done through a reconciliation bill. Most of them are among the very population Trump said he was running to give a voice to — nationally, 56 percent of those who would lose coverage are white, and 80 percent of adults who would lose insurance have less than a college degree.
The best hope for protecting the major provisions of the ACA rests with the handful of Republicans in the Senate who hold more common-sense views than right-wing ideologues like Ryan and Pence. They include: Susan Collins of Maine, who voted against a similar reconciliation bill the Senate passed in 2015 because it would also have defunded Planned Parenthood; Bob Corker and Lamar Alexander, both of Tennessee, who have said they would prefer to repeal once they can replace it with something else; John McCain of Arizona, who told reporters Tuesday that “we’ve got to concentrate our efforts to making sure that we do it right so that nobody’s left out”; and Rand Paul of Kentucky, who is concerned that repeal will greatly increase the federal debt.
Republican leaders in Congress and Trump seem eager to show that they can quickly deliver on their campaign promises. If the good of the country is not enough to give them pause, then they might consult their own political self-interest before stampeding to enact policies that will hurt so many Americans.