Friday, February 3, 2017

A Theory of Obamacare's Future

Having gotten the 2016 election so very wrong I am a bit hesitant to try and start making predictions especially since we are now in a political era where picking fights with Australia Bart Simpson style and "all lives mattering" the Holocaust are actually happening.

However I've been following the discussion about the end fate of Obamacare and would like to venture a theory as to what it might be.

To begin with we've seen a pretty major change already since that rather grim morning back in November when it was obvious to all serious observers that the health care system set up by the Affordable Care Act-with things like Medicare expansion, guaranteed issue, and state or federally run marketplaces with subsidies-was obviously going to be repealed completely. In fact, it was conventional enough wisdom that we were treated to very serious book reviews about how it's eminent destruction showed why liberalism itself was doomed in places like the new rebooted version of The New Republic.

But only a few weeks later even that stale voice of consensus wisdom called The New York Times was running major stories about how the push to repeal Obamacare has "stalled."

So what happened?

Well obviously of this is has to do with Trump's profoundly disastrous transition which is a big reason why he's the most unpopular new president in the history of political polling. There's also the very real factor what us anti-Trump people have taken to calling "The Resistance", that is the marches, and the protests, and the never ending calls and letters to Congress about any number of issues.

But even in a world where we had a smaller Women's March (or whatever) I still think the GOP Congress and Trump White House would be constrained by the reality that 20 million or so new people have access to health coverage and taking that away is going to be a hard sell for any politician, of any ideological stripe, who cares about reelection.

In other words I see four possible outcomes for Obamacare during the 115th Congress. I will list them in no particular order.

Repeal and Replace: This is the talking point that Republican politicians have been rolling out since (at least) 2010. Sure there's nothing in the Laws of Physics to say this won't happen, but by every other metric it just won't happen. The GOP has had seven odd years to write an alternative plan to the ACA and hasn't even bothered to hold hearings on it, let alone have a mark up session. Wonks and pundits have lots of "ideas" but there's a big difference between ideas and trying to deal with an industry that's one seventh of the economy and touches every American in some way. In other words if there was a "replace" bill coming Congress would have started on it, it was a grueling death march in 2009-10 after all, but they haven't. So none is coming.

Repeal and Nothing: This is probably the nightmare scenario. The ACA which governs our current system would be repealed and either through mistake or design no alternative would be passed. The individual insurance market would probably collapse, Medicaid expansion would shrink a great deal, and something like 120 million plus people (a number Senator Al Franken quoted on the radio the other day) might be "under the gun" for having "pre-existing conditions." In short it would be an epic disaster for the country, God knows how many people, and ultimately the GOP come 2018. But I can imagine a petulant Trump and confused Paul Ryan rolling out talking points about "This is all Obama's fault!" for months on end.

Repeal and Delay: This was the political stratagem devised by Paul Ryan et al to get around the very real policy problems of repealing the ACA and replacing it with nothing, while not upsetting their base by not ending all those death panels and such. It made sense politically, set up a ticking time bomb for the healthcare system that will blow up but after the 2018 elections and deal with the whole replace problem later. As the crisis of the healthcare system imploding looms demand Democrats pass a bipartisan bill that would spend less on the poor, cut Medicaid, and reign the trial lawyers (or whatever) and use that bipartisan cover to dodge the wrath of the voters come fall 2018. Or let it be a new "cliff" in American politics like the what the Republicans did with the debt ceiling where it could be a can to kick down the road under Republican Presidents and a way to take hostages and issue demands under Democratic ones

The problem of course is Repeal and Delay seems to be fading fast as an alternative so there's one left which Jonathan Bernstein (whose writing on this subject I'm heavily borrowing from for this blog post) has called....

Rename and...: Bernstein predicted this end game way back in the fall of 2011 (oh weren't those the days!) That is since taking away benefits from people is really unpopular and the GOP has never been that interested in healthcare policy when it comes to actually legislating on a national level (at least since the COBRA thing back during the 80's) the logical end game is a sort of punt where you throw rhetorical red meat to the base but don't do anything. As he put it back then:
...suppose that President Mitt Romney (or even Rick Perry) puts together a Heritage-endorsed package that entirely repeals Obamacare, and replaces (the president would say) the government takeover of health care, the death panels, and the rest of it with state-based Free Enterprise Marketplaces where private health insurance companies would use good 'ole American competition; Ronald Reagan Means Tested Vouchers to allow everyone to get insurance, and tax credits for everyone who signed up for any sort of health insurance.
In the era of President Game Show Host this would, if anything, be even easier. Hillary's death panels are gone, no more mandatory abortions either, instead all Americans are now allowed to go onto the convenient online Ronald Reagan State Based Freedom Marketplaces one can shop for a variety of Trump Approved Plans(TM) including the Gold Plan, The Titanium Plan, and The Trump Double Diamond Ultimate Plan. And the President ensures that no evil bureaucrats will ever deny you the ability to buy these plans as well. And if you're a freeloader who won't pony up, well then the new department in ICE will make sure you pay a fine.

This is of course completely different from the monstrous evil of Obamacare.

So what will happen? Well going back to the introduction of this post I am loathe to make a prediction, after all I got 2016 pretty wrong. But it's the internet so who cares.

My official odds are as follows: I suspected that the odds of "Repeal and Replace" are super duper long. The odds for "Repeal and Nothing" and very long but probably growing, largely a function of the growing chaos and dysfunction in Washington. The odds for "Repeal and Delay" are pretty long and getting more remote by the day (I haven't seen much chatter about it since at least the middle of Trump Week One). And the odds of "Rename and..." are everything else, which is guess is pretty good.

I guess there's also a chance Chuck Schumer will strike some sort of deal with Trump where Obamacare will be scaled back but not killed outright or something. But the White House's Office Of Legislative Affairs is going to have fun trying to sell that deal, what with yada-yading the Holocaust and all.

Anyway that's my theory of Obamacare's future.

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