Saturday, February 25, 2017

Listen: Obamacare will be fine.

This is going to be strange to hear, but Obamacare is probably going to be just fine -- and so are almost all of the people who have gotten healthcare from it.  There are three main reasons for my conclusion: electoral, structural, and ideological.

The most compelling reason is probably the electoral one: many politicians have good reason to be terrified of the consequences of throwing vast numbers of people in their districts off of health insurance.  Here's a map from EnrollAmerica that shows, county by county, how much the uninsured rate dropped across the continental United States. The bluer, the better:

Politics aside, you'll notice that this is a very blue map.  With few exceptions (and those mostly in very sparsely populated areas in Arizona or the Dakotas), the ranks of the uninsured have dropped.  That's not surprising; nationwide, thirteen million more people have healthcare thanks to Obamacare.

Now, many Republican politicians were happy to rail against Obamacare as long as a Democrat was president, since it's easy to attack the law: like with any healthcare reform, there were winners and losers (more on that in a bit).  But now that Republicans control both houses of Congress and the presidency, they suddenly have the burden of actual governance.  And so if they repeal Obamacare and people get hurt -- and people would get hurt -- then those people will angrily vote their politicians out of office.

Look at Oklahoma and tell me Obamacare repeal is going to be an easy sell there, after most of the state has seen their uninsured rates drop by 10-15%.

Or Alaska (which had the unpopulated northern regions lose coverage, but the populated southern areas expand coverage):

Democrats will need just three Republicans to defect from any Republican plan, and there are a lot of people who were helped by Obamacare.  Alas, they're only starting to realize that now, once it's under threat, but better late than never.  For the first time since its passage, Obamacare is popular.

"Okay," you might be saying, "but what if they repeal Obamacare but also pass something that helps those people?"

Well, first of all, that would be awesome.  If we could somehow trick Trump into backing universal healthcare and branding it TrumpCare, then I would be ecstatic.  It even seems within the realm of possibility -- Trump only seems to have convictions about the criminal tendencies of certain races and the imperative requirement to "make better deals" with other countries, so healthcare policy might be up for grabs.  If you see him, please mention how simple and brilliant a "Medicare for all" policy would be, okay?

But frankly, healthcare reform is incredibly hard for plain structural reasons, especially in a country like ours.  Insurance companies, healthcare providers, the healthy, and the sick all have strong interests in the outcome, and those interests often directly oppose others.  For example, the young and healthy want to buy little or no insurance (since they don't need it), but the sick want everyone to buy insurance (since it's the healthy people with coverage who subsidize the healthcare of the sick).  Obamacare solved this problem by requiring everyone to get insurance, but also taxed rich people to help pay for it all.

As New York's Jonathan Chait sums it up:
Obamacare was not a perfectly designed law, but it did reflect a kind of political genius. It found a way to pay for access for the uninsured with minimal disruption to the status quo. Obamacare did create some losers: The very rich pay much higher taxes, and young, healthy people have to pay higher premiums on the individual market. (The latter could one day become winners under Obamacare should they grow unhealthy or un-young.) They made a lot of noise — remember the media freak-out over the tiny number of people who lost their plans in the individual market? — but they were vastly outnumbered by the winners: millions of people who could now have access to insurance who once could not afford it.
It's just very unlikely that Republicans will figure out a better plan.  All of their current proposals would hurt millions of voters, and it will be very hard to hide that fact.  Making it even worse for Republicans is the fact that they have little time to engineer and pass a plan, and they have a lot of constraints.  Because they want to avoid a Senate filibuster from the minority Democrats (which they couldn't break, since the GOP doesn't have 60 votes), they want to basically do as much as possible through a special "budget reconciliation" process.  The first step to that process was passing a 2017 budget that set them up for repeal.  But this method means that any plan has to be revenue-neutral and can't set up a whole lot of new programs.  Further, they now have until only a few months to pass a second budget reconciliation bill (for 2018) if they want to get it before the CBO for review in time to retain some of the payment mechanisms of Obamacare in their version.  Without those pay-fors, then replacement becomes even more difficult.

The long and short of it, then, is that it's going to be hard to pass any defensible replacement.  Now, these aren't ironclad guarantees: it's entirely possible that Republicans will be fervent enough to simply repeal Obamacare without a replacement or with a replacement that's terrible.  We can't discount that tribalism will win over self-interest.  But even if Obamacare is repealed, there's still the third reason why I think it will be -- despite that! -- okay.

It is a plain fact that Obamacare has cemented in place, forever, the idea that it is the government's job to help make sure everyone has healthcare.  The attitude of past eras, where a person's poverty and sickness was just their hard luck... well, that's over.  Even if Obamacare is repealed and replaced, consigned to history, the moral imperative placed on the government will remain.  We all get together and agree on ways to govern our country, to protect our people, and to care for our poor and elderly... and now, to make sure that our sick are helped.

In 2012, Senator Ron Johnson (R-Wis) said, fearfully, “This is really our last chance of stopping this and I think we really need to run the table, or this health care law, I fear, will be implemented. The history is once an entitlement is implemented it’s extremely difficult to turn back the clock.”  He was right.

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