Sunday, May 21, 2017

Meanwhile, Back on the Healthcare Front (Remember That?)

But Donald Trump's flying circus is just entertainment t most Americans; it does not directly impact our lives.  Healthcare policy, on the other hand, can have an immense impact on a lot of people.

When we last left the Obamacare repeal, House Republicans had rushed their bill to a narrow victory before its Congressional Budget Office (CBO) score was prepared, knowing that the score would be devastating and rile up public opinion against them.  The flying circus mercifully took all the oxygen out of the news cycle last week, but in the meantime it appears that Senate reconciliation rules do not allow them to accept a bill until it is scored by the CBO and shown not to increase the long-term deficit.  So the House is awaiting the score before passing the bill on to the Senate.  The CBO score is expected to come in next week and will undoubtedly be devastating in what it shows happening to people's insurance.  Worse yet, if the latest bill is estimated to increase the deficit, the House will have to modify it and pass the damn thing all over again, this time in the face of a CBO estimate showing just how many people it anticipates will either lose their health insurance or see premiums soar.  And what will happen in the Senate is anyone's guess.

But Republicans should not despair.  Even if nothing passes at all, Donald Trump appears to be well on his way toward crashing the exchanges all on his own.  His inconsistent messages to the insurance industry and sheer incom

petence is leading many of them to flee the exchanges or raise their rates. No one knows whether anything will pass Congress and, if so, what it do.  Trump has sent hopelessly confusing mixed signals about whether he intends to enforce the penalty for not having insurance, which is necessary to keep younger and healthier consumers in the mix.  He has also sent mixed signals on whether he intends to keep the cost-sharing reductions or CSR's, a system for partially paying the deductible for low-income consumers.  At one point one of his surrogates even offered to continue paying the CSR's if insurance companies would support repeal -- which would, of course, mean an end to the CSR's.

My guess would be that for many Republicans this would be, if not the ideal outcome, the best one they can realistically hope to achieve.  By crashing the exchanges and stripping 10 million people of their health insurance it will, after all, destroy half of the hated Obamacare, and in a way much less politically damaging than if they had actually passed a bill.

After all, if Congress had actually passed a bill, it would own the consequences.  Republicans have been doing their best to gloss over what all serious sources regard as the most likely outcome of their bill, and with some success.  But if the bill passes and millions lose their health insurance the next year, there will be no glossing over that.  Nor will there be any way to blame Obama since their bill, after all, passed with great fanfare.  If, on the other hand, their bill fails and then the exchanges crash, that will be easy to blame on Obama.  Republicans can always argue that they did their best to pass a bill to save the exchanges, but it failed, mostly due to resistance by those evil Democrats.  It will be a blatant lie, of course.  Their proposed bill would also strip millions of their health insurance, and Trump has been openly proclaiming his intent to sabotage the exchanges.  But Trump followers will eagerly accept this story and low-information voters will find it at least plausible.  Complete destruction of the exchanges will also prevent Democrats, should they return to power, from repairing them, and hopefully make the whole issue so toxic that Democrats will never attempt to expand health coverage again.

Of course, there will still be problems.  For one thing, crashing the exchanges won't actually repeal,sthe taxes that support them.  But once the exchanges crash, it will be easy to defend repealing a tax to fund a program that no longer exists.  It will also leave the Obamacare regulations still in place, but only the Freedom Caucus really cares about that.  

Since the regulations have not been repealed, crashing the exchanges may bring down the individual insurance market altogether.  That, I believe, is something Republicans genuinely don't want to happen, as no government is involved in the individual market off the exchanges.  But on the bright side, it will create a good argument for repealing the regulations and create more problems to blame on the Democrats.  In other words crashing the individual market, though undesirable, might be acceptable collateral damage.

Finally, crashing the exchanges won't roll back the Medicaid expansion, so about half of Obamacare will still stand.  But crashing the exchanges while leaving the Medicaid expansion in place should increase working class Trump supporters' resentment of poor people on Medicaid and increase the pressure to roll back the expansion eventually.  

So all in all, I am inclined to think that Republicans may see crashing the exchanges as optimal.

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