For years, like the dog that chases the car, Republicans in Congress have chased their own holy grail, repeal of the Affordable Care Act, otherwise known as Obamacare. And like the dog that finally catches the car, the question becomes: “What now?”
It, of course, is one thing to titillate the GOP base by passing one Obamacare repeal measure after another when you know the president is going to issue a veto. But with Donald Trump soon to occupy the White House, the question of what to replace it with comes to take on a lot more significance.
Even most Republicans understand that there’s no going back to the bad old days of 50 million uninsured Americans, skyrocketing premiums, and insurance companies denying coverage to anyone who actually needs the coverage due to illness.
But when it comes to drafting an alternative, the Republicans face a number of problems, among the biggest is that Obamacare was already the Republican version of health care reform. Indeed, the framework of Obamacare, including the individual mandate and public subsidies to make private health insurance affordable for more Americans, was dreamed up in the conservative halls of the Heritage Foundation and was first implemented by Republican Mitt Romney in Massachusetts. Obama adopted the idea in the naïve hope that he could win some Republican backing in Congress.
Yet it leaves the Republicans with the obvious question? How do you make a Republican-inspired health reform measure more “Republican.” And how do you replace Obamacare without instituting a new program that looks an awful lot like, well, Obamacare?
One thing Republicans seem to agree on is to put an end to the insurance mandate. But that’s a lot tougher to do than it sounds, particularly when President-elect Trump has already said he wants to keep the prohibition on denying coverage for pre-existing conditions. That’s one of the most popular parts of Obamacare and it’s one that most Americans understand, since most everyone had a family member who couldn’t get insurance in the past because they were a cancer survivor or had a costly, chronic illness.
Yet if insurance companies have to sell you a reasonably affordable policy, regardless of your medical status, many people will recognize that they are best off doing without insurance until they actually need it. You don’t need insurance, after all, to get a check-up once or twice a year. If that’s all you do, insurance is a shockingly poor investment.
That’s especially so for young people, who are generally healthier, which is why they haven’t signed up for insurance at the rate that Obamacare advocates had hoped to see. For many of them, it’s far cheaper to pay the relatively modest penalty for failure to comply with the mandate than it is to buy insurance they probably won’t need, at least in their youth. That’s part of the reason that health insurance premiums have jumped so quickly in the individual insurance market. Young people were supposed to, in effect, subsidize the health care bills for older, sicker people in the individual insurance pool. But since they haven’t signed up with enough frequency to do so, actual medical bills have outpaced premium revenue for most insurers, who have responded by raising rates through the roof.
Do away with the mandate, as Republicans propose, and that problem will only grow worse. The insurance industry, a major funder of GOP candidates, would never accept a requirement to issue coverage to everyone that isn’t tied to a mandate that everyone buy insurance. That was the Faustian bargain struck by Obamacare, and it’s a tough one to work around. Without it, the insurance industry would likely revolt.
So what do the Republicans do? Maintain the mandate? Or tell insurers they can drop sick people again? Governing (as opposed to standing in the way of governing as the GOP has done for eight years) can involve sometimes difficult choices— and leave you facing the criticism, rather than directing it. That’s a lesson that the GOP is likely to learn the hard way.