Obamacare Isn’t Gone Yet, But It Is Doomed

by and

Congress today took a major step toward killing the Affordable Care Act, using an unusual procedure to lay the groundwork for an eventual repeal that would leave as many as 30 million people uninsured. It’s the culmination of a 6-year-long effort by Congressional Republicans to return the American health insurance system to the breathtakingly horrible state it was in before the law’s passage.

Republicans in the House passed a budget resolution that the Senate approved on Thursday to set the stage for a parliamentary maneuver called reconciliation. The budget measures do not actually repeal the law, but rather direct committees in both chambers to draw up plans to do so. And because they were technically passed as part of the budgeting process, they’re immune to filibuster, requiring only a simple majority to pass. With Republicans dominating both houses (Republicans hold 52 of a total 100 seats in the Senate and 241 of 435 seats in the House), and an incoming president who ran on the law’s destruction, Democrats will be powerless to defend against the eventual total repeal.

If the action today sounds vague, that’s because it is; there is essentially no public, detailed proposal yet, and that’s not likely to change in the coming days, or even weeks. The specifics of exactly which parts of the law will be excised and how quickly those changes go into effect will need to be worked out. But if the GOP keeps its gleeful promises to gut the law — and “replace” it with some as-yet undescribed substitute scheme — millions of lives will be disrupted—some irreparably.

What Happened Today

The bill that was passed today can be thought of as a blueprint for a future plan, says professor Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University.

“It gives instructions to each house about what to do,” Nichols says of the budget measures. “And then the committees will take over,” to work out the details. By passing the bill as a budgeting document, GOP leaders make sure that the plans coming out of those committees are immune to filibuster. Republicans now have, in many ways, carte blanche to reshape the law in dramatic fashion or scrap it outright, even if they have nothing to replace it with. They’ve announced no consensus plan on how to do that, and Nichols notes that there are deep disagreements on how best to proceed, even within the GOP caucus. All that is yet to come.

“The question is when will the repeal take effect, and how long before the replace details are revealed,” Nichols says. Congressional Republicans set a self-imposed January 27th deadline for repeal proposals that was initially opposed by a few Republican senators. But they withdrew their opposition after agreeing to make the deadline non-binding—and given that there have thus far been no details offered describing what a viable alternative will look like, it’s possible we’ll wait much longer than that for a new plan to emerge.

What is Likely to Happen in the Near Term

Not much, Nichols says. From the plans that have been floated so far, it looks unlikely that dramatic changes will come in the near future. But what the GOP is contemplating will be hugely disruptive to the healthcare market, not to mention the lives of millions of Americans. In theory, a repeal could take effect the month it is passed, but it is more likely that any changes will be phased in over one or more years. “I would say it’s very unlikely that there will be any change until 2018,” says Nichols. That we don’t yet know what will happen spells trouble for states who must create budgets and insurance companies who set rates far in advance.

What Is Likely to Happen Eventually

There could be a dramatic scaling back of current Medicaid subsidies that currently make healthcare affordable — or more affordable — for about 30 million people. That could even “go away completely” Nichols says. That would return the system to a more or less purely market driven one, much like the one that was working very, very poorly before Obamacare came into effect.

The change could also reverberate far beyond just those who receive healthcare through the ACA.

The loss of insurance and disruption to the market could potentially cause personal healthcare debt to balloon so sharply that employee premiums for everyone will rise—while wealthy people see tax breaks—said Andy Slavitt, acting administrator at the Centers for Medicare and Medicaid Services, in a tweet. We could see a return to sexist insurance practices like charging women higher premiums and monetary lifetimes limits on insurance coverage.

What’s Not Likely to Change

Some popular aspects of the law, like the coverage of preexisting conditions and the stipulation that young people can remain on their parents’ plan until age 26, are unlikely to be scrapped, Nichols says. They’re too popular. But Nichols says that the GOP is going to be in for a rude awakening when they actually have to write a workable plan.

“What’s going on right now, and I must say I take some pleasure in this — the Republicans are leaning a lot about the details,” Nichols says. “They never had to pay attention because they were never in a position to write legislation that would actually take effect. The attempts to “repeal” Obamacare in the past were all stunts, Nichols says, “show pieces for the base” that they knew would never be enacted.

“But now it’s real.”