A Belated Post on the (Surprisingly Not Late) ACA
I was going to get to a political post at some point prognosticating about the fate of the ACA, but then time passed and prognostication became just gnostication. But maybe not so much!
It didn't surprised me when the Republican proposal went with the "free lunch" version of the repeal (the prohibition on "preexisting condition" bans is popular, the mandate is unpopular, so just get rid of the latter, what can possibly go wrong?). The ACA was the Republican plan for restraining healthcare costs, it shouldn't be surprising that the new proposal was basically the same three pillars of require insurers to offer insurance, encourage people to buy insurance, and subsidize. (Though, for one thing, the alternative version of the "encouragement" pillar seemed obviously too weak. If you want to encourage healthy people to buy insurance, a policy that encourages people to buy insurance for the first two months after they've left coverage and then discourages them is not ideal.)
The bit that did surprise me was the complete failure of the bill. I'd assumed after all the hype that the vote would be whipped somehow.
There's a split in the Republican opposition to "Obamacare", between a faction that primarily wants to just repeal the "Obama" part and a faction that (though it has no fondness for Obama) primarily wants to repeal the "care" part. Siderea has a post with an excellent analysis of this, breaking down the Republicans among the "Repealists" (who would still be happy voting for a flat repeal of the ACA, followed by further cuts to Medicare and Medicaid), the "Replacists" (who accept that affordable healthcare should be made available somehow but think the Republicans can do that cheaper and better; Trump himself is in this camp, so unsurprisingly many Trump supporters are as well), and the "Parochialists" (who are primarily focused on the fact that their constituents won't vote for them again after their insurance becomes expensive or unavailable). The latter two factions were in fact willing to join in on voting in favor of a straight repeal, but only so long as that would be safely vetoed.
The bill did have some things that all of those factions could like: Big deficit-funded tax cuts that disproportionately benefit the rich (deficits don't matter, right?), cuts in consumer protections that would allow insurance companies to sell junk insurance (which could make it seem like a decrease in costs). But it was not enough.
So what next? Trump wants to wait in hopes of a better negotiating position. Ryan also seems eager to get on to other things. It's not clear whether either a flat repeal or any innovative (in the sense of not just being some version of Romney/Obama/*care) conservative healthcare policy reforms will make it to a vote in the near future.
It didn't surprised me when the Republican proposal went with the "free lunch" version of the repeal (the prohibition on "preexisting condition" bans is popular, the mandate is unpopular, so just get rid of the latter, what can possibly go wrong?). The ACA was the Republican plan for restraining healthcare costs, it shouldn't be surprising that the new proposal was basically the same three pillars of require insurers to offer insurance, encourage people to buy insurance, and subsidize. (Though, for one thing, the alternative version of the "encouragement" pillar seemed obviously too weak. If you want to encourage healthy people to buy insurance, a policy that encourages people to buy insurance for the first two months after they've left coverage and then discourages them is not ideal.)
The bit that did surprise me was the complete failure of the bill. I'd assumed after all the hype that the vote would be whipped somehow.
There's a split in the Republican opposition to "Obamacare", between a faction that primarily wants to just repeal the "Obama" part and a faction that (though it has no fondness for Obama) primarily wants to repeal the "care" part. Siderea has a post with an excellent analysis of this, breaking down the Republicans among the "Repealists" (who would still be happy voting for a flat repeal of the ACA, followed by further cuts to Medicare and Medicaid), the "Replacists" (who accept that affordable healthcare should be made available somehow but think the Republicans can do that cheaper and better; Trump himself is in this camp, so unsurprisingly many Trump supporters are as well), and the "Parochialists" (who are primarily focused on the fact that their constituents won't vote for them again after their insurance becomes expensive or unavailable). The latter two factions were in fact willing to join in on voting in favor of a straight repeal, but only so long as that would be safely vetoed.
The bill did have some things that all of those factions could like: Big deficit-funded tax cuts that disproportionately benefit the rich (deficits don't matter, right?), cuts in consumer protections that would allow insurance companies to sell junk insurance (which could make it seem like a decrease in costs). But it was not enough.
So what next? Trump wants to wait in hopes of a better negotiating position. Ryan also seems eager to get on to other things. It's not clear whether either a flat repeal or any innovative (in the sense of not just being some version of Romney/Obama/*care) conservative healthcare policy reforms will make it to a vote in the near future.