Whither the Affordable Care Act now? Consider its contentious history.
2009: Republicans on the bipartisan Senate “Gang of Six” walk away from further negotiation and no Republicans – not one – vote for the ACA.
20l0: ACA takes hold, as does a continuous chant of “repeal” by Republicans.
2014: Republicans gain control of both houses of Congress.
2015: The “repeal” cant is replaced – except in the most radical segment of the GOP – with “repeal and replace,” because it dawns on opponents that the ACA is signing up millions of newly insured people, many of them happy to be insured.
2016: With a Republican president making the federal government wholly GOP, the new chants are “Obamacare is in a death spiral” and “repeal and replace on Day One.”
2017: On Day One, President Trump injects the first poison into the ACA’s veins: an executive order instructing all agencies to “waive, defer, grant exemptions from or delay its rules.”
2017: On Day 53, the Congressional Budget Office reports that the health insurance market “would probably be stable in most areas” under either the ACA or the proposed GOP replacement plan, so long as the government continues to subsidize low-income policyholders.
2017: On Day 64, repeal and replace dies an ignominious death. Trump predicts once more that the ACA will go away: “It can’t do well. It’s imploding and soon will explode and it’s not going to be pretty.”
2017: Day 69, Secretary of Health and Human Services Tom Price tells a congressional committee, “Fourteen hundred and forty two times the ACA says ‘the secretary shall’ or ‘the secretary may’” and “we’ll look at every single one” for any opportunity to execute Trump’s executive order.
And so the stage is set not for outright repeal or repeal and replace or any effort to fix the system. It’s set for sabotage.
Here’s how it will happen, unless Trump and Price recover their consciences or congressional Republicans hear enough from back home to fear for their political lives in the 2018 elections.
The ACA’s 1,442 “shalls” and “wills” each represent a dial that Price can tweak on his own – at least until he’s taken to court.
He cannot unilaterally do away with the core requirement that everyone buy insurance or pay a penalty – the mandate reviled by the GOP. Any large health insurance plan requires a mandate, because no insurance company can charge reasonable rates if its policyholder base is only sick or elderly people. But Price can dial back how vigorously the mandate is enforced. And as fewer healthy people enroll, more insurance providers will have to drop out.
He already has cut back the HHS effort to sell the plan through advertising and other informational campaigns. He can cut back on “essential benefits,” the list of things that all insurers must offer.
He can dial back the cost-sharing subsidies offered to low-income participants who are having problems paying their out-of-pocket expenses, driving away even more insurance companies. And the White House can help Price by not opposing in court a challenge by House Republicans that the subsidies are illegal.
In short, Trump’s Day One executive order made willful neglect backed by callous cruelty the nation’s new health policy. It enables Price to fulfill the persistent Republican predictions of the ACA’s collapse, depriving millions of Americans of insurance protection they need, and all while blame the Democrats.
Davis Merritt, a Wichita journalist and author, can be reached at email@example.com.