During the Obama years, congressional Republicans could rail away at the Affordable Care Act and vote endlessly to repeal it, secure in the knowledge that they would never have to deal with the consequences of repeal actually happening. At the same time, they could claim they wanted to keep the popular parts (protections for people with preexisting conditions) without explaining how that might be accomplished while jettisoning the unpopular parts (the individual mandate).
But now, repeal has suddenly become a reality. President-elect Donald Trump’s choice of GOP Rep. Tom Price as Secretary of Health and Human Services underscores that he is dead serious about going forward with repeal-and-maybe-replace. Which means congressional Republicans (who will have to vote on repeal and then later maybe on replace) now have to grapple with the consequences of repeal actually happening — and with the challenges of keeping the stuff people like while blithely tossing out the stuff they don’t.
Talking Points Memo has a good piece that captures the contortions this is forcing Republicans to put themselves through right now. There are a number of questions they are trying to resolve: How can we keep protections for people with preexisting conditions while scrapping the mandate that keeps the insurance pool from getting too old and sick? How much can be repealed through “reconciliation” and a simple-majority Senate vote? All of those are difficult problems.
But I wanted to focus for the moment on one particular question: What will Republican legislators from states that have expanded Medicaid do? Note this quote that TPM got from Senator Shelley Moore Capito, a Republican from Trump-friendly West Virginia:
“I’m from a state that has an expanded Medicaid population that I am very concerned about….I don’t want to throw them off into the cold, and I don’t think that’s a strategy that I want to see. It’s too many people. That’s over 200,000 people in my state. So we need a transition. I think we’ll repeal and then we’ll work during the transition period for the replacement vehicle.”
Capito knows that repeal would mean 200,000 of her constituents lose health coverage. And it turns out there are many other GOP Senators in a similar situation.
According to the Kaiser Family Foundation, 32 states have adopted the Medicaid expansion so far. By my count, next year there will be over 20 Republican senators in those states. (The ones that are expanding Medicaid and have one or two GOP Senators are Alabama, Alaska, Arizona, Arkansas, Colorado, Indiana, Iowa, Kentucky, Louisiana, Montana, Nevada, North Dakota, Ohio, Pennsylvania, and West Virginia.)
The interesting nuance here is that before, GOP governors in those states could expand Medicaid even as GOP Senators in them continued to call for Obamacare’s repeal (with nothing happening). But now they will have to cast a repeal vote that actually means taking health care away from untold numbers of their own constituents.
And repeal of the Medicaid expansion is now a very real possibility. Congressman Price — Trump’s pick to head HHS — has offered a repeal plan that rolls it back entirely. Price has offered a replace plan, but some experts think it would likely leave most of the 20 million people who would currently lose insurance after repeal without coverage.
Regardless, even if Republicans do fully intend to try to provide a replace plan that does cover most of those currently on the Medicaid expansion, it isn’t going to be easy, and it’s going to require spending money. That’s why Republican Senators in Medicaid expansion states — such as Capito above — are claiming they are going to transition those people to a new plan after repealing Obamacare, while cautioning that it will take awhile. Others are predicting it could take years.
“Republicans are going to have a tough time coalescing around a replacement plan, and it is going to take time,” Larry Levitt, a senior vice president at the Kaiser Family Foundation, tells me. “This is enormously complicated stuff with difficult tradeoffs. Insurance coverage for millions of people is at stake.”
There was a time when I would have confidently predicted that Republicans who do vote to toss huge numbers of their constituents off of health coverage, without replacing it, would pay a political price for it. I’m no longer sure that’s true. It’s very possible that Republicans may end up repealing Obamacare while vowing a replacement in time that somehow never ends up materializing, because the details prove too difficult, or consensus proves elusive, or the base doesn’t allow it. Alternatively, a replacement that leaves many current Obamacare beneficiaries without coverage is also possible.
Still, you’d think some Republican Senators might be as troubled by such an outcome as Capito at least appears to be, and you’d think some will genuinely wrestle with the policy complications of replacing Obamacare, and in the process will find out that it’s a lot harder than expected. In this sense, at least, consequence-free railing about repeal might have been a lot more fun than actual real-world repeal might turn out to be.
