So far, the Affordable Care Act has proved a remarkably durable piece of legislation. It’s survived a flubbed rollout, uncooperative state lawmakers, two Supreme Court challenges, more than 50 repeal votes in the House, and multiple attempts to replace it since Republicans took control of Congress and the White House. Whether it survives Mitch McConnell’s extraordinary legislative coup is, as of press time, anybody’s guess. On July 25, the Senate majority leader squeaked through a motion to begin debate on a bill that will impact tens of millions of Americans and one-sixth of the US economy. How so? Nobody knows exactly—because the bill hasn’t been written yet.
What emerges from the negotiations to follow could be a repeal-only bill favored by conservatives like Rand Paul and Ted Cruz, which would strip health coverage from 32 million Americans and double premiums within a decade. Or it could be a so-called “skinny repeal” that eliminates the individual mandate while ducking issues like cuts to Medicaid that have turned off moderates. Most likely, if anything passes the Senate at all, it will be larded with amendments designed to buy off both factions, all written behind closed doors, without markups, hearings, or input from Democrats. To repeal (and replace) Obamacare, McConnell still has a narrow path to tread, but he has correctly identified that the only road to victory lies through chaos, secrecy, and panic.
Even without any legislative action, those will be the instruments the Trump administration uses to cripple the Affordable Care Act behind the scenes. “We’ll let Obamacare fail, and then the Democrats are going to come to us,” Trump told reporters last week. “Let Obamacare fail” really means make it fail—a strategy the White House has been flirting with for months. In April, Trump threatened to cut off the payments to insurers (known as cost-sharing reductions) that help to decrease out-of-pocket costs for lower-income people. If he does so now, insurers will either raise premiums or exit the market completely. Trump could also choose not to enforce the tax penalties for people who forgo insurance, or to refuse to advertise enrollment periods, both of which would destabilize markets even further.
Yes, the ACA’s individual marketplaces are already unstable in some areas. There may be no insurers offering plans in more than three dozen counties in Indiana, Nevada, and Ohio next year. Premiums are expected to rise. But a more basic problem is that the people now overseeing Obamacare would like to see it fail—specifically Health and Human Services Secretary Tom Price and the administrator of the Centers for Medicare and Medicaid Services, Seema Verma. Both trumpet every piece of bad news about the “collapsing” markets, while doing nothing to prop them up. Insurers themselves have explained that the Trump administration’s actions (or lack thereof) are one of the primary reasons for instability and premium hikes.
Outside the White House, a collapse of the repeal effort may make a few Republicans more willing to consider improving Obamacare. To that end, Congress could permanently fund cost-sharing reductions to insurers, boost reimbursements to insurers for high-costs patients, and fix other small glitches in the law. It could also create a public option to boost competition in the Obamacare market, though that’s obviously a far heavier lift.
For activists working to preserve Obamacare, the main priority now is to expose the Republican leadership’s machinations and to mobilize massive public pressure against any repeal effort. “As long as Mitch McConnell is the majority leader, we’re not going to take anything for granted,” said Angel Padilla, the policy director for The Indivisible Project. Padilla said he won’t feel certain that repeal is off the table until Republicans start working in earnest to strengthen Obamacare via bipartisan legislation. Even then, he warned, advocates should be wary of harmful amendments and a continued assault on Medicaid.
Also on the horizon is the ongoing struggle to expand Medicaid in the 19 states that have not done so. According to the Kaiser Family Foundation, about 4.5 million people would gain coverage if those states decided to expand their programs. In March, Kansas’s Republican-controlled Legislature approved the expansion, though it was vetoed by Governor Sam Brownback. Maine residents will vote on an expansion referendum in November. In North Carolina, the Democratic governor and Republican Legislature are locked in a fierce standoff over the issue.
Then there’s the brewing push from the left for universal coverage through a Medicare-for-all system. Al Gore, hardly a fringe figure, recently endorsed the idea, and Senator Bernie Sanders is set to introduce legislation to that end in the coming weeks. A new Pew survey finds that public support for such a system has steadily grown, even as Republicans have repeatedly tried to ram through an Obamacare repeal. Some 60 percent now say the federal government is responsible for providing health care to all Americans. In their craven and anti-democratic putsch against an increasingly popular program, Republicans may have awakened a formerly silent majority—one that will not only defend the current law, but rally around the simple principle that health care is a right for all, and not a privilege for the few.