james debate
james debate

Friday 28 July 2017

The first months of the Donald Trump presidency have seen little in the way of legislative accomplishment. Without getting too speculative, there are many reasons why this Congress and this White House have not been especially productive, but chief among those reasons would have to be the heavy focus to date on healthcare. Indeed it has been all over the news, to the point where even the politically apathetic are probably aware that Trump and the Republicans are trying to do something with healthcare. The headlines have been full of buzzwords like "Trumpcare",  and "Obamacare repeal". Indeed Trump himself has declared frequently that Obamacare is already "dead". But what does all this actually mean, what exactly is/has/will be done, and what does it mean for the American patient?

trump obamacare trumpcare make america sick incompetence repeal death panels mccain

What is Obamacare?
The Patient Protection and Affordable Care Act ("ACA"), frequently referred to as "Obamacare" was a wide-ranging reform of American healthcare passed into law by then President Barack Obama. I will refer to it as Obamacare in this article, as this is the term with which most will be familiar.

Without getting too bogged down in the detail provisions of this law include children being able to stay on their parents' healthcare plan until the age of 26, greater protections for patients who would otherwise be refused insurance for having "pre-existing conditions", and tighter regulations on when patients can and can't be refused care. It greatly expanded the existing Medicaid program to cover anyone below a certain income threshold, and provided significant investment to medical research and healthcare infrastructure in order to bring the system into the 21st Century (these included, for example, online health insurance exchanges to give people greater freedom to find a plan that fits their needs).

All of this was paid for through a combination of new taxes, mostly targeted at the wealthy, and through a so-called "insurance mandate", which ultimately was more of a tax on people who did not buy health insurance, therefore incentivising otherwise healthy people to buy insurance and therefore contribute to the insurance pool for those who need it.

The effect of this law has been to expand healthcare coverage in the United States, achieving nearly universal coverage, and to control rising premium costs, which have largely stabilised since the law's passage. As a result of these benefits, Obamacare is generally a very popular law, scoring a high plurality or low majority of support in most recent polls, comparable with most laws that get passed. The specific provisions themselves have proven to be wildly popular in polls.

Obamacare is fairly popular, so why do Republicans oppose?
Describing the Republican opposition to Obamacare is difficult. For sure there are many things that can be improved with Obamacare, many things that need to be fixed, many bugs to be remedied. Strangely, these problems never get mentioned by Republicans, instead they have objected to the law from its inception for other reasons, including:

  • It was rushed into law, despite being debated over a 10 month period;
  • It was passed without any Republican input, despite the fact that votes were held on over 100 Republican amendments, many of which were ultimately included in the law, and despite the fact that many of the law's key provisions were based on previous Republican proposals;
  • The so-called "insurance mandate", despite this having been a key pillar of Republican healthcare policy since the 1960s, part of their national proposal in the 1990s, and part of many Republican Governor's statewide policies;
  • The expansion of Medicaid as an overreach of Government, despite many Republican Governors opting into the new expansion, and doggedly defending it during the current "repeal" debates;
  • New taxes.
As you can see, the logic behind many of these objections can be a bit inconsistent, and that's without even mentioning the ones like "death panels" and "Government takeover", which in retrospect are probably even embarrassing to the Republicans who used them. The only one on that list which doesn't require doing a complete 180 on longstanding Republican policy is the objection to new taxes. Strangely, there has been almost no noise about the actual flaws with the law, like the Medicare Part D donut-hole. Many more cynical observers have suggested the real reason has more to do with simple tribalism; Obama did it, therefore we oppose it. 

Whatever the reason, a full repeal of the law has been a core part of the Republican platform these past eight years, and now that they are in power with the White House and both chambers of Congress, many had expected them to follow through on this ambition.

The Republican Healthcare Plan
So what exactly have Republicans been proposing? What have they accomplished so far? Is Obamacare "dead" as Trump claims?

First thing is first. Obamacare is most certainly not "dead" despite the President's soundbite. It is still very much law, and that won't change until a full repeal of the law is passed by the House of Representatives, by the Senate (almost certainly requiring a filibuster-proof 60 vote majority), and then signed by the House. This has not happened yet, and as such the law is still law, and essentially unchanged from its status under Democratic governance.

So far, the House of Representatives has passed the American Healthcare Act of 2017 ("AHA"). The Senate has voted against this bill, and has also voted against two additional healthcare bills, the Better Care Reconciliation Act ("BCRA") and Health Care Freedom Act ("HCFA"), the so-called "skinny repeal". So at the moment, the Senate has voted "no" on three separate bills. If they vote yes on the House-approved AHA they can send it straight to the President for signature. If they vote yes on either of the other two, the House then needs to vote on it first. If the House and Senate can't agree on legislation, the two will enter a committee process in order to come up with a compromise bill, if one is possible.

So the current state of play is... not much has changed. The Republican controlled Congress so far can't agree on a bill to pass into law, and therefore the law remains unchanged.

But Obamacare WILL be dead, right?
So Republicans can't agree on a way to repeal Obamacare, but surely it's just a matter of time. After all they control the White House and both chambers of Congress. Surely they will eventually come up with a compromise and repeal that Obamacare once and for all, right?

Well actually, none of these bills, literally none of these bills, will repeal Obamacare. 

A repeal of Obamacare, actually removing it from law, will require 60 votes in the Senate. Republicans currently have 51, and no Democrat has shown themselves so far to be interested in cutting back people's access to healthcare. As a result, all of these proposals so far are so-called "budgetary reconciliation" bills, effectively just a budgetary adjustment of existing law, which only requires 51 votes to pass the Senate. 

So they're not even voting to repeal Obamacare?
Nope, they're voting to defund specific parts of it, a process which can be just as easily undone by the next Government, and has absolutely no longstanding effect on the Obamacare law itself. None of these laws repeal Obamacare, they just defund healthcare in America.

So why is Trump calling Obamacare "dead"?
Because he's a salesman, and he knows that the only thing voters care about is the perception. Make no mistake, if he could repeal Obamacare and replace it with an identical law called "Trumpcare", he would do it.

So do these bills actually do anything?
Yes, still very much so. The actual impact depends on the bill in question, but range from taking away access to healthcare from 22 million people (in AHA and BCRA) to 16 million people (in HCFA). All the bills in question would increase premiums significantly.

So these bills may not be an actual repeal of Obamacare, but their effect on sick people would still be significant. The good news is they can be easily undone by the next Government.

So where do we go from here?
Hard to say. The two likely scenarios are:
  1. Republicans pass some form of minor budgetary adjustment, declare Obamacare "dead". Next President just refunds Obamacare and we forget all about this charade.
  2. Republicans are unable to come up with a compromise and move on, defund healthcare services and then blame "Obamacare" for the deficiency.

What can we learn from all this?
The current Government is fairly incompetent, and they think the American voters are really stupid.

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