Wednesday, March 15, 2017

Between Obamacare and A Hard Place

In terms of being "the dog who caught the car" the GOP's control of the whole federal government (for some definitions of "control") may be the best example ever. Having run on repeal of the ACA in 4 elections, failure, at this point, "is not an option."

The problem is that "repeal" (a) at its most basic will create electoral chaos by leaving lots of people who want insurance without it and (b) anything short of basic repeal won't satisfy conservatives who want that. It's either a conservative / base revolt or a vulnerability of unknown size in the next few major elections.

The Reality

The ACA was optimized to increase coverage--both by brute force with the Medicaid expansion and by removing barriers such as the pre-existing condition lock-out. Remember: if you were in the private market there was a time when you couldn't get coverage for pre-existing conditions at any price. The ACA did away with that--but the cost was the Individual Mandate.

The GOP has the opposite problem: The Medicaid expansion probably did the most to insure poor people of anything in the ACA (remember, most people still get insurance through their employers) but that's the sort of thing the GOP is ideologically opposed to. Sure, grandma may get to live longer--but it's at a great cost to the nation, yadda, yadda.

The GOP can't really admit this--but now that they hold the controls, they're in a bind: they have to "compromise" with their principles and that isn't pretty.

Even Worse

Even worse is that the messaging dilemma that has plagued the GOP since they decided they were "okay" with racist voters votes--but still had to be on-message against racism (among other problems) hasn't gone away with a great victory. Now they have powerful factions that want different things and they have to find a way to talk about these that (a) sounds coherent and (b) sounds kinda like Democrats.


Well, yeah. Ryan is pretty clear that he wants to "shrink government." Everyone can agree with that--until their constituents get shrunk. Trump rode to victory claiming, literally, great health care for everyone. It turns out? People believed him.

This, combined with Trump's lack of leadership (he says he'll primary anyone against the current bill--but hasn't, and won't--put his name on it. And, for example, Breitbart attacking Ryan over the bill while Bannon sits at Trump's right hand) leaves nobody clear what they ought to be saying, let alone doing.

Right now everyone is romancing the Trump--but we know how that ends: he agrees with everyone and then does something random.

The End Game

Since failure isn't "an option"--both for Trump who has gotten his negotiator-skill(z) put on the line and for the GOP in general--they need to pass something. Ergo, something will be passed. The question is what is the minimum sub-set of reductions that can pass for "repeal"?

The Omnivore predicts two major modifications to the current state of Health Care:

  1. Officially change the name of the Affordable Care Act to "Obamacare"
  2. Officially change the name of Obamacare to "The Ryan Act" (some conservatives will object to the term 'care' in any description of the bill)
That should satisfy "everyone."


  1. By objecting so strenuously to Obamacare for so long, and for so many reasons, the GOP entangled itself in a position where it basically rejected all the stuff that might work and which isn't entirely incompatible with Republican Orthodoxy. The argument that the ACA is originally a Heritage Foundation plan is... not really right at all, but the components are still ones that are either part of the US healthcare system already (Medicaid) or innovations the GOP was willing to accept.

    Rejectionism not only got them a plan that they liked less than they would have otherwise, it foreclosed on a lot of future avenues for repair and improvement.

  2. Regardless of any change other than full repeal without anything replacing it, it will still be ObamaCare - just modified (something the law always intended to have happen).. it doesn't matter what they call it.