President Trump and House Speaker Paul Ryan (R-WI) now acknowledge that the Affordable Care Act will remain the law of the land for the foreseeable future, following last week’s debacle in which they were forced to pull the Republicans’ repeal and replacement plan before it was put to a vote in the House.
They argued for months that Obamacare was in a “death spiral” and would eventually collapse of its own weight, but that alone wasn’t a compelling enough argument to rally Republican lawmakers in the House and Senate behind the Republican’s alternative approach. Moreover, analyses by the non-partisan Congressional Budget Office (CBO) showed that Obamacare wasn’t in dire financial straits and that 24 million Americans would lose health care coverage by 2026, including 14 million by choice.
Now, in the wake of last Friday’s GOP legislative train wreck, the Trump Administration and Republican congressional leaders are facing a critical choice: Should they continue to pursue a destructive and seemingly vindictive course to further undermine Obamacare in hopes of fulfilling their gloomy prophecy? Or should they join with Democrats and more moderate Republicans in seeking ways to fix the worst problems of a program that has insured more than 20 million Americans?
Over the weekend, the Trump camp and some congressional Democrats signaled that some sort of political rapprochement over health care was not out of the realm of possibility after months of bitter conflict in which the Democrats stood united against any GOP plan. All sides agree that something needs to be done to strengthen the financial position of insurers, beef up competition, and slow the rate of growth of premiums and out of pocket costs. But if history is any indication of what to expect, the chances of a bipartisan agreement to strengthen the existing program seem unlikely at best.
During their separate press conferences Friday to try to explain why they failed to pass the GOP American Health Care Act, Trump and Ryan both seemed to be rooting for Obamacare to fail, notwithstanding the adverse effect that would have on millions of Americans who receive subsidized private insurance or expanded Medicaid through the program.
“I hope it does well; I would love it to do well. But it can’t do well; it’s imploding and soon will explode, and it’s not going to be pretty,” Trump said in the Oval Office.
Trump voiced interest in working with Democrats, but only after they came to the realization that Obamacare was a failure. Ryan told reporters at the Capitol that Obamacare is “so fundamentally flawed” that he didn’t know whether it was even possible to prop it up.
On Sunday, however, the administration and congressional Democrats signaled that there might be room for bipartisanship to address some of Obamacare’s more glaring problems. The growing exodus of major insurers like Aetna, United Healthcare and Blue Cross-Blue Shield from the Obamacare market has many policymakers in both parties spooked.
Senate Minority Leader Chuck Schumer of New York said on ABC News’This Week that he could foresee room for negotiations going forward, provided Trump and the Republicans abandon their crusade to repeal the Affordable Care Act. “They ought to get rid of repeal – drop it – it’s been a flop for them . . . and work with us to improve Obamacare,” Schumer said.
White House chief of staff Reince Priebus continued to insist that Obamacare is fundamentally flawed and “is going south,” during an appearance on Fox New Sunday. But he wouldn’t rule out the possibility of a cooperative effort later this year to prop up the existing program, and said it was important that the Democrats ultimately “come to the table.”
“I want people out there to understand this president is not going to be a partisan president,” Priebus said. “This is a president that wants to make sure people don’t get left behind; he wants to make sure there is competition in the marketplace so that rates are lower and people can choose their doctors.”
“So if those three things are incompatible with some members of the Republican House, then we need to work with moderate Democrats to make sure that that happens,” he added.
Joseph Antos, a health care expert with the conservative-leaning American Enterprise Institute, said that a more cooperative effort is not out of the question if both sides find a way to tone down their partisanship and accept the fact that Obamacare is here to stay. “Absolutely, there are a lot of fixes that could and should be made,” he said.
But that would be a tall order politically and begs the question of how the White House and Democrats could strike a compromise on health care over the almost certain objections of members of the House Freedom Caucus and other conservatives who are still clamoring for the complete repeal of Obamacare.
If the past is prologue then the Trump administration and the Republicans in Congress will probably double down in trying to crush Obamacare with many techniques that already have been road-tested by the Republicans over the past several years and since Trump took office Jan. 20.
Those tactics include reducing advertising and recruitment activities, weakening the enforcement of the ACA’s “individual mandate” requiring people to obtain coverage, cutting federal spending to underwrite unforeseen losses by insurers, and sharing in the out-of-pocket costs of low-income policyholders.
Obamacare managed to survive two major court challenges that reached the Supreme Court and scores of Republican efforts on Capitol Hill to defund and dismantle the program over the years. Yet, GOP lawmakers led by Sen. Marco Rubio of Florida were instrumental in the closing of many of the 23 non-profit insurance plans under the ACA in 2015 and 2016 by blocking federal assistance to many of the coops that had incurred heavy operating losses.
House Republicans also went to court to block Obamacare cost-sharing subsidies for lower-and-middle-income people arguing they were unlawful because they hadn’t been specifically authorized by Congress. The Obama administration challenged an adverse federal court ruling in May 2016 that has put the subsidies on hold, but the new Trump administration might allow House Republicans to prevail in killing the subsidies.
Shortly after taking office in late January, Trump signed an executive order designed to undercut the Affordable Care Act by instructing the Department of Health and Human Services and other agencies responsible for administering the program to find ways to ease the burden of the law on individuals and businesses. The Internal Revenue Service responded in early February by weakening the health care law’s requirement that individuals either acquire health insurance or pay a tax penalty to the government.
Over the coming weeks and months, the White House and Health and Human Services Secretary Tom Price – an arch foe of Obamacare -- will be faced with a number of choices over “whether to shore up insurance marketplaces created under the Affordable Care Act – or let them atrophy,” The Washington Post reported over the weekend.
For 2917, the federal exchanges signed up or auto-renewed 9.2 million Americans, down by about 400,000 people from the previous year. That dip was due in part to the Trump administration’s decision to curtail recruitment efforts in the final week of the enrollment season. Overall, an estimated 12 million people have enrolled in both federal and state-operated insurance markets this year, which typically drops when the first premium payment is due.
Insurers and consumers are operating in an environment of uncertainty over the future of Obamacare, especially if Trump and Ryan take further measures to drive the program into the ground. That uncertainty could lead to another round of rising premium costs and diminished competition and policy choices heading into the 2018 insurance season.
Larry Levitt, senior vice president of the Kaiser Family Foundation, told The Post, “The administration could do everything from actively undermining the law to trying to reshape it to moving it in a more conservative direction.”