Thursday, November 17, 2016

Generic Republicans in Power: Obamacare

Now in power, Republicans are having to deal with responsibility.  What they could safely propose when it had no chance of occurring will now actually happen if it passes, and they will be held responsible for it.  How much they can get away with depends on how much public resistance there is to it.  

I am absolutely confident that they will pass a large tax cut, with most of the benefits accruing to the top.  That is what they do.  They have done it every time they have gotten the chance since 1981, and they will do it again this time.  They will be successful because, although there is no great public demand for such a tax cut, neither is there any particular opposition to it either.  It is a high priority of the Republican donor class, strongly opposed by the Democratic elite, and a matter of general indifference to the wider public.  It will pass without too much difficulty.

Healthcare, now, is a different matter.  Plowing Obamacare under and sowing the field with salt has been the top Republican priority ever since it passed, shared by donors and voters alike, and meeting with little resistance by the broader public so long as it was purely theoretical.  But now practical reality has struck.  The exchanges are running into serious problems, but if the Republican response is simply to shut down the exchanges and kill the subsidies, they will cut off the way 10 million people get their health insurance.  10 million people will be very upset and will flood the airwaves, Congressional offices, town hall meetings and the like with outraged complaints.  The pressure will be on Republicans to do something about it.  

And then there is the Medicaid expansion.  Another 10 million will lose health insurance if the Medicaid expansion is repealed.  Some people have suggested that there will be little political cost to that because poor people don't vote often and certainly don't vote Republican.  But the outcry won't just be from recipients.  Hospital will be outraged at having so many unpaying patients foisted on them.  States (many of them with Republicans controlling at least one branch) will be greatly alarmed that the hole being blown in their budgets.  Remember all the outcry Democrats receives when they passed Obamacare?  Well, the Republicans will be on the receiving end of it if they attempt to take health insurance from 20 million people.

Of course, Republicans realize this.  While they may or may not wish to strip 20 million people of their health insurance, Republicans must certainly know that they will pay a steep political price if they do.  That is why they all agree on the formula "repeal and replace."  The general consensus is that they will pass an early bill repealing Obamacare in its entirety in two years, putting the pressure on themselves to come up with an alternative by then or 20 million people will lose their health insurance.  As long as they were out of power, Republicans could propose health savings accounts and insist that if they just limited medical malpractice awards and allowed competition across state lines, costs would fall enough to bring health insurance within everyone's reach.  In power, they will quickly learn that a lot of people can't afford health savings accounts, and that being told insurance will be within their reach a few years down the line is not much comfort to a seriously ill person who needs it now.  So they will have to come up with something.

The trouble is that any major policy change has losers as well as winners -- and that the losers are a lot louder than the winners.  When Obamacare came into effect, we heard a lot from people whose plans were cancelled because they no longer met regulatory standards, and a lot from healthy young people whose rates were increasing to subsidize older and sicker people.  We hear a lot now from people who find that high deductibles and narrow networks are seriously limiting the benefit they derive from their health insurance.*  So guess what?  Republican plans will lead to lower rates for younger and healthier buyers, but higher rates for older and sicker ones.  Somehow I don't think older and sicker customers will take it peacefully.  It will mean skimpier benefit packages and more people becoming outrages over things that aren't covered.  Any while Republicans are now outraged at the high deductibles and narrow networks under Obamacare plans, their plans tend to encourage even higher deductibles and narrower networks.  All of this will lead to uproars -- just like the Obamacare implementation led to uproars.  One alternative to this might be simply to kick the can down the road and extend Obamacare a few more years to give themselves time to come up with a better plan.  I had thought that an extremely likely scenario, but this article convinced me otherwise.  It pointed out that if insurers don't know if the exchanges will be there in another year, they probably won't be willing to sell policies on them.  So the uncertainty itself could be enough to kill the exchanges. 

Of course, to some Republicans simply delaying until the exchanges crash from uncertainty might seem like a great deal.  They can destroy the hated Obamacare, see everyone who got insurance through the exchanges lose their coverage, and blame Obama for the outcome.  Or maybe not.  Maybe the outcry from people threatened with loss of insurance will place the blame on Republicans.  Or maybe Republicans can leave the current system in place and just repeal the hated mandate.  Then they could induce a death spiral on the exchanges, ensure that everyone who got health insurance there would lose it, and be reasonably able to blame Obama for it.  Win all around!

*Incidentally, that has been my experience as well.  I make just enough money not to qualify for a subsidy, but have enough of it vanishing into student loans that health insurance is a serious squeeze. It adds insult to injury to go in for what I thought was routine preventive care and find out that they have found ways to exclude it.  And if they are doing diagnostic tests for a possible problem instead of purely routine preventive care, those are charged.  On the other hand, insurance does get you a considerable discount for services compared to what the uninsured are charged.

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