Both Donald Trump and Congressional Republicans have long promised to “repeal and replace” the Affordable Care Act, popularly nicknamed Obamacare.  The repeal part is easy, the replace part… well not so much.  In the last Congress, secure in the knowledge that the Senate or a Presidential veto would ensure their bills would never become law, the Republican majority in the US House of Representatives voted 60 times to repeal Obamacare.  Not once did they even bring to the floor a plan to replace it.  However, now that they will control both houses of Congress and the White House, they are coming to the realization that they cannot afford to repeal the program without eventually putting into place a replacement plan.

It is easy to understand why.  The Republicans understand that some provisions of Obamacare are almost universally popular and they dare not repeal them.  However, they also know that popular Obamacare provisions like the elimination of preconditions and lifetime coverage caps along the ability of young adults to stay on their parents’ policies cannot stand alone.

Alone these provisions would drive up the cost of everyone’s insurance premiums significantly.  Other ACA provisions allow doctors and hospitals to collect insurance payments for treating millions of people who were previously not covered.  This allows them to avoid raising health care prices for the rest of us because they no longer have to cover the costs of treating those people who otherwise couldn’t afford to pay for their care.  Those provisions work to keep the price of health insurance down for all of us while countering the costs of the very popular aspects of the system and at the same time providing the assurance of reliable health care for those millions of additional people.

The various parts of the Affordable Care Act work together and removing any of its important provisions will cause it to fail spectacularly.  An apt analogy would be a three legged stool.  Remove one leg of the stool and it can no longer stand.

However, the biggest incentive for the Republicans to replace Obamacare with something that works just as well involves a political calculation.  The Republicans don’t want to be viewed as the “bad guys”.  Imagine for a moment what would happen if Obamacare was repealed and not replaced. Over 20 million people now receiving insurance from the ACA exchanges and expanded Medicare coverage would no longer have insurance.  They would still need medical care, even though many of them can’t afford to pay for it.  These people would again turn to hospital emergency rooms where legally they cannot be turned away, but where the cost of treatment is much higher than in a doctor’s office.  In some cases their minor problems could become much more serious without proper care making their illness more costly to treat. Medical insurance costs would again begin to skyrocket.

However, most of that would happen behind the scenes without much media coverage.  What the Republicans really fear is the stories which the media certainly will feature.  Imagine a deluge of stories involving people who were previously insured under Obamacare who died because they didn’t get proper care, or whose relatively minor illnesses are now much more serious because they didn’t get proper care early on.  Imagine numerous stories about hard working families who lost their insurance coverage and who were wiped out financially by a serious illness or accident.  The Republicans know they can’t afford to be blamed for these types of horrific situations, so the repeal of Obamacare without a suitable replacement is really not an option.

However, that leaves Trump and his Republican allies in Congress with a major problem; they have yet to come up with a viable replacement plan, and they are not likely to do so any time soon, if ever. Remember, that their primary reason for wanting to repeal Obamacare is because they don’t want the government involved in the insurance business.   They also don’t want anyone forced to buy insurance, another provision of the ACA which lowers insurance costs by forcing healthy young people into the insurance market  They also want to decrease government spending and reduce taxes.

This is where reality sets in.  Most of the people covered by the ACA could not afford their insurance premiums on their own.  75% of the 20 million people now covered by the Obamacare have some or all of their premiums covered by government subsidies,  and providing subsidies is against Republican conservative principles.

Republicans are finding it extremely difficult if not impossible to figure out how to provide insurance coverage to even most of the people currently insured under Obamacare while staying true to their core principles.  Several Republican solutions have been proposed, but they would either be ineffective and/or they don’t have wide support.  None of the measures proposed the would cover the most needy among us.

However, the Republican base is demanding that Obamacare be repealed immediately, and after seven years Congressional Republicans still have no viable replacement plan. What to do?  Apparently they plan to follow the example of football teams that have run out of offense options, they plan to punt.

It is becoming clear the Republicans in the House and Senate are working on bills which will repeal the ACA program now, but will delay the implementation of the repeal for some period of time, perhaps three years.  With that approach they can satisfy their core constituents immediately and inform the public that they are giving themselves time to come up with a replacement plan that really works. They are also perhaps hopeful that they can force the Democrats to help them come up a replacement plan so they can share the blame when it goes South.

However, even that approach has severe risks in the real world because of the way that the insurance industry will react.  If insurance executives know that Obamacare is going away, why would they elect to stay in the exchanges and continue to put in the time and effort to make their presence profitable?  As soon a delayed repeal plan is passed by Congress and signed by Trump, the ACA program will enter a death spiral.

That’s why President Obama’s advice to the Congressional Democrats is sound – don’t get involved in Republican efforts to replace the ACA program.  Let the Republicans take all of the credit and all of the blame for their efforts.  Label any Republican effort to change the Affordable Care Act in any manner Trumpcare.  That appears to be a sound approach to me.  The Republicans created this situation; let them use it to hang themselves.

Cajun    1/7/2016