Meanwhile, here is a selection of news reports from the past two weeks:
The Obama administration announced that the number of people signing up for insurance through HealthCare.gov, the federal website that 39 states use to administer Obamacare plans, is even higher than last year. State-run sites such as Covered California are reporting similar surges.
An independent think tank, The Commonwealth Fund, published a study showing that fewer people are skipping medical care because of cost ― most likely because, thanks to the health care law, so many more people have health insurance.
Standard and Poor’s Global Ratings reported that insurers selling Obamacare plans are seeing better financial results this year, suggesting that premiums are finally coming into line with the actual medical expenses of their customers ― and that this year’s big rate hikes may be a “one-time pricing correction.”
It’s possible that Ryan thinks these and similarly positive news items are irrelevant ― that the Wisconsin Republican has deluded himself into thinking Obamacare really is an unmitigated policy disaster, rather than a fairly typical government program full of pluses and minuses and the inevitable implementation complications that large reform efforts usually overcome.
It’s also possible that Ryan’s crusade to pass repeal in January has nothing to do with policy and everything to do with politics ― that he wants Congress to vote before the rest of the country, and maybe even the president-elect, wakes up to the real-life changes such a vote would unleash.
What “repeal and delay” would mean in real life
Ryan and his allies envision a quick, surgical strike on Obamacare soon after Donald Trump takes office, via what’s come to be known as a “repeal and delay” strategy. The idea is to eliminate Obamacare’s funding, using a special legislative procedure reserved for bills related to the budget, while leaving most of Obamacare’s coverage provisions in place for a year or two or maybe three. In theory, the more than 20 million people now relying on the program would hold onto insurance while Republicans craft their replacement scheme.
Even conservative experts doubt this gambit would work out so neatly. Insurers that tolerated early losses in Obamacare marketplaces in the hopes of realizing future profits aren’t going to stick around for a market that’s about to disappear ― particularly if the repeal bill also takes actions, such as eliminating the individual mandate, that would tilt the insurance customer base even more toward unhealthy people with high medical expenses. If enough carriers flee, a recent analysis from the Urban Institute predicted, millions of people would lose their health insurance in just the first year.
And it’s not like Republicans can guarantee that, after a transition period, they would have a new health care scheme in place and ready to go. It’s been more than six years since Republicans first promised to craft an Obamacare replacement, yet they are nowhere near a consensus on what such a replacement should look like.
The House has a set of reform principles with no dollar figures, the Senate doesn’t even have a set of principles, and President-elect Trump has a set of vague talking points that could mean he endorses some traditional conservative ideas, like allowing insurers more freedom to sell coverage across state lines, or that he’s never given these specific proposals more than 10 minutes of thought.
This intellectual disarray should not be surprising. Finding consensus on health care policy is hard once the trade-offs become apparent ― when lawmakers discover, for example, that it’s difficult to require insurance coverage for people with pre-existing conditions without making sure that healthy people are also paying into the system.
Obamacare’s approach, a combination of subsidies for individuals who buy insurance and penalties for those who do not, isn’t the only one. But the alternatives, which range from single-payer on the political left to high-risk pools on the political right, don’t make those policy trade-offs disappear. They simply move the trade-offs around. Lower premiums for the young tend to mean higher premiums for the old, less regulation on insurers usually means less protection for consumers, and so on.
The prospect of repeal with so much uncertainty about a replacement has already drawn carefully worded criticism from a handful of Republicans, including Sens. Lamar Alexander (Tenn.) and Susan Collins (Maine). Alexander’s warnings about the perils of haste are particularly important because he’s a senior, widely respected member of the Senate ― and because he is chairman of the Health, Education, Labor and Pensions Committee, which has direct jurisdiction over health legislation.
Why Ryan and his allies want that repeal vote now
But Ryan and his allies aren’t slowing down, at least not so far, and there are likely two main reasons.
One is that the repeal bill is likely to dictate the size and shape of an eventual replacement, by stripping out Obamacare’s revenue ― including some $350 billion in taxes that fall exclusively on the wealthiest Americans. Cutting upper-income taxes is a perennial priority for Republicans. But without that money at the disposal of lawmakers, it’s pretty much impossible to craft a conservative scheme that would come anywhere close to the scale of insurance coverage that Obamacare does.
Sure enough, the schemes conservatives envision would all result in far fewer people covered, greater exposure to medical bills even among those with insurance or a combination of those two. The ones hit hardest would be the people without a lot of disposable income, the ones with serious medical problems and (worst of all) the people who fall into both categories.
The other likely reason to rush a repeal vote would be to avoid public scrutiny of both its short- and long-term effects.
For all of the controversy swirling around President Barack Obama’s signature health care law, and for all of the genuinely negative feelings the public has about it, its core elements remain highly popular. Those elements include not just protection for people with pre-existing conditions but also the availability of financial assistance for people who can’t afford coverage on their own ― which, in a recent Henry J. Kaiser Family Foundation poll, a whopping 80 percent of Americans said they support.
The same Kaiser Foundation poll found that roughly half of Americans want to keep Obamacare in place or expand what it does. Another 17 percent merely wants Congress to scale it back, while just over a quarter want full repeal ― and even that enthusiasm wanes when respondents learn that repeal might mean eroding the law’s consumer protections.
An extended debate over repeal, the kind that Democrats endured in the 14 months they spent crafting health care reform, might focus public attention on the disconnect between what it wants and what Republicans are proposing ― and suddenly repeal might not seem very attractive politically.
Republicans, particularly those from safely conservative House districts, might be telling themselves that their voters want full Obamacare repeal, regardless of what the public as a whole desires. If so, they should look more closely at that Kaiser poll, which showed even Republican voters divided over whether to support full repeal. Or maybe Republican lawmakers should listen to the Trump voters that Vox’s Sarah Kliff interviewed in Kentucky and that the Atlantic’s Olga Khazan interviewed in Pennsylvania.
These voters weren’t Obamacare fans, for sure, and many said they were angry other people seemed to be getting more financial help paying for insurance. But these voters were in no mood to restore the pre-Obamacare status quo.
Many said they hoped for a new system that provided more coverage rather than less, and quite a few were actually grateful for their Obamacare insurance ― even if they didn’t always know it came from Obamacare. “I’m afraid now that the insurance is going to go away and we’re going to be up a creek,” one Kentuckian told Kliff.
What Trump really thinks and wants
It’s not clear how many other Republican voters are feeling the same fear ― or whether Trump himself has come to grips with what a quick repeal vote, without a replacement in place, would entail.
As The New York Times’ David Leonhardt noted on Tuesday, Trump’s blustering about Obamacare frequently included promises to replace it with something better. “We have to take care of the people that can’t take care of themselves,” Trump said during a Fox News debate. “Everybody’s got to be covered,” he told CBS’s “60 Minutes.”
Those statements could have the same meaning as anything else Trump has said ― which is to say, they could have no meaning at all. Come January, Trump might simply outsource health care policy to members of his administration, starting with Vice President-elect Mike Pence ― who, from the looks of things, is in lockstep with Ryan.
But Trump has a history of endorsing the principle of universal coverage and it’s possible that he really thought repealing Obamacare would be a prelude to something even more far-reaching and comprehensive. If so, that would put Trump very much at odds with what Ryan and his allies are proposing to do.
The only question would be whether Trump, and the public at large, realize in time to act.