If Republicans can set aside the recriminations and Democrats their gloating over the death of the GOP's "repeal and replace" Obamacare legislation last week, they might want to devote themselves to something far more worthwhile — healing the ailing Affordable Care Act. As much as President Donald Trump may believe "Obamacare is exploding," that's not really the case. Rather, it's suffering from some relatively small but growing problems, all of them quite correctable if those involved devote themselves to caring for the patient and not killing it.
It's pretty safe to say, that's what the American public actually wants. Just look at the polls like the Kaiser Family Foundation's most recent showing the controversial-from-the-start ACA hasn't been this popular since 2010. As much as Friday's death of the GOP's American Health Care Act has been reported as a political event — chiefly as a result of discord within the Republican ranks (Senate v. House, moderates v. conservatives, establishment v. tea party, President Trump v. House Speaker Paul Ryan, take your pick) — it's too easy to ignore what an extraordinarily bad piece of legislation that proposed Obamacare replacement was. In simple terms, Trumpcare would have had two major impacts: the removal of millions of Americans from the health insurance rolls and a huge tax break for the wealthy.
And don't take our word for it, that's how the nonpartisan experts at the Congressional Budget Office saw it. Their report forecasting 24 million fewer Americans would have health insurance and that insurance premiums would rise steeply for older people was probably far more instrumental in stopping the repeal-and-replace movement in its tracks than any intrigue within the House Freedom Caucus. Who wants to campaign on that achievement? Politically, Republicans were fortunate it quickly withered on the vine.
Practically from the start, the biggest problem with the ACA has been the misrepresentations made about it. It isn't "government-run health care" but a fairly complex health reform law based on a bipartisan Massachusetts model (Romneycare) that sought to reduce the number of uninsured, reduce the cost of health care, and level the playing field so that, among other things, people with pre-existing conditions could afford health insurance. The mechanism for providing these benefits was a system of subsidies, mandates and state-run exchanges where people who don't have insurance through an employer could purchase a policy on the individual market from private insurance companies.
So what's the problem? What's gotten the most attention are the significant rate hikes on those health exchanges. Some states like Arizona have gotten hit hard, but some states have not, and either way, most beneficiaries don't really feel the increases because they are covered by subsidies. Still, the chief problem appears to be simple economics — in some parts of the country enrollment has not been as high on the individual market as expected and those who have enrolled have been sicker than expected. A lack of competition has worsened the problem. Most experts predict that the markets should stabilize, nevertheless, but they'd probably improve considerably if more states signed on to the Medicaid expansion, if the federal government enforced the individual mandate, and better yet, if it increased the penalty for those who fail to buy insurance.
The greatest danger facing the ACA is not that it will implode, explode or enter into a death spiral but that the Trump administration will seek to exacerbate its shortcomings. The administration has already been busy doing just that by reducing marketing and promotion of the program to get fewer people to sign up. Earlier this year, President Trump instructed the IRS not to reject 2016 tax returns that fail to indicate whether the individual has qualifying health insurance coverage, effectively letting people off the hook for the individual mandate. And there are probably dozens of other ways Republicans can sabotage Obamacare through the regulatory process or by simply reducing the Medicaid budget.