The growing opposition to ACA “repeal and delay”

Republicans in Congress are pressing forward with a plan to repeal the Affordable Care Act through a budget reconciliation process, which requires only 50 votes but can only eliminate the portions of the law that affect the federal budget. They don’t yet have a viable plan to replace it, so they’re pushing a “repeal and delay” strategy that would involve repealing the law now and asking voters to trust them that they’ll come up with something else in a few years (on top of the six they’ve already had). That something else would almost certainly involve skimpier coverage or the loss of insurance entirely for millions of Americans.

The “repeal and delay” approach would allow Republicans to fulfill a campaign promise to repeal the ACA, but it would harm their constituents directly and indirectly. The GOP wants to get rid of the individual mandate and the big federal subsidies to insurers, but without them the market for individual insurance coverage will collapse (see last month’s post for more details). An Urban Institute analysis of the partial repeal of the ACA through the budget reconciliation process warned that the resulting situation will be worse than the pre-ACA status quo. Linda J. Blumberg and her colleagues write:

The number of uninsured people would rise from 28.9 million to 58.7 million in 2019, an increase of 29.8 million people (103 percent). The share of nonelderly people without insurance would increase from 11 percent to 21 percent, a higher rate of uninsurance than before the ACA because of the disruption to the nongroup insurance market.

Of the 29.8 million newly uninsured, 22.5 million people become uninsured as a result of eliminating the premium tax credits, the Medicaid expansion, and the individual mandate. The additional 7.3 million people become uninsured because of the near collapse of the nongroup insurance market.

Some of my colleagues at the George Washington University Milken Institute School of Public Health analyzed the likely economic impact of repealing the ACA’s tax credits and Medicaid expansion without a replacement. As millions of people lose their insurance, revenue for hospitals and other healthcare providers would drop sharply, and that would in turn affect state economic activity and tax revenues.  Leighton Ku and his co-authors write:

Repeal results in a $140 billion loss in federal funding for health care in 2019, leading to the loss of 2.6 million jobs (mostly in the private sector) that year across all states. A third of lost jobs are in health care, with the majority in other industries. If replacement policies are not in place, there will be a cumulative $1.5 trillion loss in gross state products and a $2.6 trillion reduction in business output from 2019 to 2023. States and health care providers will be particularly hard hit by the funding cuts.

So, to recap: 30 million people lose their insurance, 2.6 million people lose their jobs, and states lose $2.6 trillion — but the GOP can keep a campaign promise!

Some Trump voters who benefit from the ACA have said they didn’t think Trump would let their coverage vanish. As details emerge of what Republicans actually aim to do, though, a new Kaiser Family Foundation poll finds that only 20% of the public support the “repeal and delay” option. (Forty-nine percent say they want the law repealed, but the majority of them want to have a replacement plan first.)

The two main US hospital trade groups (American Hospital Association and Federation of American Hospitals) warned last month that repealing the ACA without a replacement could cost them billions of dollars and lead to “an unprecedented public health crisis.” A letter from four major provider groups (the American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and American College of Physicians) to Congressional leaders warns that ACA repeal “would have a profoundly negative impact on our health care system and the more than 200 million people who currently have health care coverage through the individual, small group, and employer-based markets, as well as Medicaid.” These four groups urge lawmakers considering changes to the ACA refrain from increasing the number of uninsured, ensure a viable health care safety net, and ensure vital patient protections in the health insurance market.

Republican governors of Arkansas, Michigan, and Ohio have emphasized how much Medicaid expansion has benefited their states, but those benefits would disappear quickly if this ACA provision were repealed.

At the Daily Intelligencer, Jonathan Chait zeroes in the fact that GOP leaders complained about the speed at which the ACA was rushed through Congress — and are now trying to repeal it far more quickly and with far less discussion of the implications. Chait writes:

[The ACA] spent a year working through Congress, eventually passing numerous committees, two full House majority votes, one Senate supermajority vote and, in fact, many, many, many hearings. While the law did use a budget-reconciliation bill to enact minor fiscal adjustments, a maneuver that Republicans decried as akin to a death blow to the Republic, in fact its major provisions all received 60 votes in the Senate. The bill was evaluated by the independent Congressional Budget Office, and the projected premium levels in the new exchanges turned out to be accurate, and its predictions of overall federal health spending turned out to be too pessimistic, as the federal government is now spending less on health care with Obamacare than it was projected to spend without it. The bill was enacted in a democratic, deliberate, transparent, and excruciatingly slow fashion.

But the claims that conservatives have falsely made about passing Obamacare provide a true description of the Republican plan to undo it. They are rushing through a bill to repeal it with maximal speed, and no public deliberation.

Chait also points out that Trump promised a healthcare plan to “take care of everybody” but that the Republican Party’s actual policy agenda is “to eliminate or minimize the government’s commitment to expanding health coverage.” Such an approach, however, is at odds with what the clear majority of Kaiser Family Foundation poll respondents want. Ashley Kirzinger and her colleagues report:

When presented with two general approaches to the future of health care in the U.S., six in ten (62 percent) Americans prefer “guaranteeing a certain level of health coverage and financial help for seniors and lower-income Americans, even if it means more federal health spending and a larger role for the federal government” while three in ten (31 percent) prefer the approach of “limiting federal health spending, decreasing the federal government’s role, and giving state governments and individuals more control over health insurance, even if this means some seniors and lower-income Americans would get less financial help than they do today.”

I understand the urge to reduce federal spending in the abstract, but in this case the specific consequences are extreme: an estimated 30 million people lose their insurance, 2.6 million people lose their jobs, and states lose $2.6 trillion.

Most of us would like to see some improvements to the ACA — in fact, President Obama suggested some in a JAMA editorial last summer — but that doesn’t mean scrapping the whole law is the right approach. Provider groups and voters seem rightly skeptical that Republicans can repeal most of the ACA now and then be trusted to come up with something comparable or better at some undetermined point in the future.