President-elect Donald Trump and Republicans in Congress have voluntarily put themselves under extreme pressure to put together an Obamacare replacement plan as soon as possible. And they're moving full speed ahead: A midnight budget resolution vote cleared the way for ACA repeal, even after five GOP Senators publicly appealed for a delay to the process.
So, is Obamacare repeal turning into a Kamikaze-style piece of political suicide? The answer is no, because it's likely the leaders of the "repeal it now" movement are going to lean on some political and public relations tricks and gimmicks: They're going to keep more of the existing parts of Obamacare than expected, tweak a few others and publicize a few new ideas to get the biggest public relations effect.
1) Drafting a plan and implementing it are two different things
So far, all we've heard from Trump and the other more aggressive replacement advocates is a call to get an Obamacare replacement "drafted" or "passed." That's a heck of a lot easier than putting a new plan into effect. And more importantly, it's the best and most likely way out of the biggest risk involved in ditching the ACA, which would be the angry reaction of millions of Americans potentially getting insurance cancellation notices in the mail. The good news is that passing a plan and then waiting a year or two to put it into effect is a process the public is used to with big government programs.
2) They don't have to start from scratch. They already have Medicaid
Much of the existing ACA infrastructure is not only good, but contains many attributes Trump and Republicans at least claim to like. First and foremost, you have a national website where millions of Americans go to shop, compare, and sign up for health insurance. Trump and the Republicans have been calling for years to allow health insurers to compete across state lines and the existing ACA website is there to facilitate that process.
But it will also be essential because the replacement plans we've seen so far from the Republicans all include putting more responsibility and choice into the hands of consumers when it comes to getting their own health insurance. Using tax credits and other funding pathways to do that is the hard part, but thanks to the ACA and that website the "buying health insurance for yourself" part is easy.
Some of the other aspects of the ACA that aren't as popular with Republicans will still likely remain because it's too easy to keep them and too hard or politically toxic to trash them. Chief among them is Medicaid and the expansion of it that most states accepted as part of the Obamacare plan. Political optics plays a big role in this part of the deal, because throwing millions of the poorest Americans off of Medicaid rolls would look even worse than throwing middle class people off of their private insurance plans.
But there's a silver lining here for the replacement process, and it comes from a very surprising source: Controversial economist and Obamacare architect Jonathan Gruber, You'll recall that Gruber was the one who publicly said that the passage and construction of Obamacare regulations relied on "the stupidity of the American voter." But Gruber has a new study out that shows that the clear majority, (70 percent) of the Americans who supposedly became eligible for Medicaid because Obamacare loosened the requirements were actually eligible all along.
In other words, Obamacare's biggest impact may not have been the creation of anything but new awareness of a very old government program dedicated to the simple idea of getting health care to the people who have the most trouble affording it. And this provides Trump and the Republicans with a major escape pod and fast track towards passing and implementing an Obamacare replacement.
Remember that the big reason why so many mostly red state governors rejected the Medicaid expansions in their states was because they feared the federal aid money to fund the expansion would eventually end and then the new enrollees would become another unfunded state burden. But the Gruber report shows that 70 percent of those new Medicaid users were already the federal government's responsibility.
Of course, this would probably put added pressure on Washington to do something about those growing Medicaid costs. But that will be a lot easier to do than crafting and funding an Obamacare replacement. Look for Medicaid and promises to boost funding for it to become a key cornerstone of the Republican replacement plan.
3) Window dressing is easy
A cereal company can add a minuscule new ingredient to its product and get away with calling it "new and improved." Politicians can do that too, and Obamacare is filled with opportunities to make little tweaks here and there. Some very small degree of tort reform, which was discussed before the ACA was passed, is one example. And targeted tax credits to help people set up health savings accounts would be another. We know Trump is a master at public relations and certainly has the ability to make many possible small changes seem big or at least trick us all into talking about them for some time.
But make no mistake, there still is no fully fleshed out GOP plan to replace Obamacare. We still need to hear more details on the call to use tax credits to make health insurance for the middle class and rich more portable and not reliant on employers. We still need to know how risk pools will be funded properly to make sure the sickest and most costly health care consumers don't lose access.
And again, how the GOP and the White House are going to get that added funding Medicaid needs either way is a complete mystery right now. A lot of those blanks will be filled in over the coming days and weeks, but there's a good chance the Republicans will be pushing a message not unlike Nancy Pelosi's infamous, "we have to pass it to see what's in it," comment.
The Obamacare replacement plan will be a lot about the packaging. And that's Trump's best strength. His confidence in puffing his brand and products is probably a big reason why he's pushing the Republican Congress to hurry up and get a plan passed that he can promote. The President-elect is betting that no matter how quick and dirty the new plan is, he'll be able to sell it to most of the American people.