(This article by Joe Alton first appeared in the Daily Caller.)
A Republican plan to repeal and replace Obamacare, the American Health Care Act (AHCA), has been proposed and some conservative members of congress are, to put it mildly, not on board.
Kentucky senator Rand Paul calls it “Obamacare Lite”. Congressman Justin Amash (R, MI) tweets “Obamacare 2.0”. The Freedom Caucus, a group of about three dozen GOP house members, are skeptical and could sink the new plan all by themselves. A number of conservative think tanks are also unhappy with the proposal.
These principled Republicans are right to have reservations about the plan. They suggest that replacing subsidies with tax credits is just another form of entitlement. They (correctly, I believe) complain that the bill will be too costly and goes against the conservative goal of less government.
One of the major sticking points in the AHCA is the continuance of the Medicaid expansion that now involves 31 states, a number of which have Republican governors. While many members of congress want to eliminate the expansion, supporters (including some GOP governors and senators) are asking an important question: What about the 11 million Americans that become uninsured as a result? Is there a risk to creating these health care “orphans”?
Medicaid is the safety net for 60-70 million U.S. citizens. Under the American Health Care Act, the expansion would continue through 2020. If the current system is abruptly eliminated, millions of Americans will, once again, find themselves without health care. This is a dilemma for Republicans: They’re walking a high wire that requires the fulfillment of a promise to repeal Obamacare while maintaining health insurance for multitudes of voters.
Conservatives want repeal and replace in one fell swoop, but the plan, for now, calls for action in three phases. In “phase 1”, The GOP will use executive actions and a simple majority to defund Obamacare and pass financial aspects of replacement through “budget reconciliation”. HHS Secretary Tom Price can unilaterally institute cost-cutting and other measures in “phase 2”. The final dismantling of the Affordable Care Act requires 60 votes in the senate to survive a filibuster, a good reason why traditional legislation has been pushed to “phase 3”.
This gradual approach drives conservatives nuts, but anything other than a stable transition is risky business. Make no mistake, everyone is aware that Obamacare is an entitlement. Despite the partisan way it was crammed down our throats, an entitlement is difficult to take away once given. GOP efforts to remove access to health care for millions on Medicaid will have consequences; consequences that might be felt as early as next year’s elections.
When I wrote about this issue earlier, someone commented that those on Medicaid, for the most part, are not Republican voters. This may be true, but propagating the (false) belief that Republicans are mean-spirited and uncaring by penalizing these folks is a political error.
Let’s think, for a moment, about probable 2018 Democrat ads against Republican governors and members of congress if Medicaid expansion is discontinued. “Under Governor Smith’s watch, hundreds of thousands of families lost their health care.” Or, “Representative Jones didn’t care enough about this family’s (insert image of average American family) health to allow them to keep their coverage. Vote Democrat in 2018!” In some states, the effect could mean the difference between victory and defeat.
Perhaps my opinion is colored by my profession, but it doesn’t take a medical degree to know that, when Obamacare dies, Republicans should create as few orphans as possible.
The price tag on Medicaid expansion has been a hefty one, but losing governorships, state houses, and, perhaps, even the House of Representatives, carries an even higher price for conservatives and the country.
The Patient Protection and Affordable Care Act (Obamacare) provided neither patient protection nor affordable care. That’s on the Democrats; what happens moving forward, however, is on the Republicans. If they want to stay in power, they’ll need to work together towards President Trump’s stated goal: To increase access and make high-quality health care more affordable. If the death of Obamacare creates health care orphans, there must be a way for the American Health Care Act to adopt them.
Joe Alton, MD