Wednesday, November 9, 2016

Obamacare: Dead Law Walking!

There is no doubt that Obamacare is dead.

The only question is just exactly how Republicans will get rid of it.

While Republicans have the votes they will need in the House, Republicans will not have the 60-vote Senate supermajority necessary to get rid of all of it. Therefore, they will use their slim Senate majority and Senate budget reconciliation rules. It takes just 51 Senators to make spending decisions.

There are two routes they will consider:
  1. Immediate repeal and replace that can rebuild insurance reform under the Senate 51-vote budget rule. Following this route will mean that the pre-existing condition reforms, for example, would have to remain in any new law because they are not budget related and would have to stay. The individual mandate (the Supreme Court declared it a tax) could be done away with as well as all of the exchange subsidies and the Medicaid expansion because they are spending related. Just what this path would look like in detail will depend upon what Senate budget rules ultimately determine to be budget items and whether that would be enough to build a health law consistent with a Republican vision.
  2. Effectively repealing by using the Senate 51-vote budget rules to gut the financing of the law on a future date certain. That would be followed by the Republicans saying to the country and the Democrats that Obamacare would continue as is until that future date––Obamacare would continue to cover everyone in the exchanges and under Medicaid. But if Democrats didn't cooperate in legislating a new health insurance law, they will argue, it will be on the head of the Democrats that people lost their coverage on the day funding ends. This course could have the effect of forcing the Congress to agree on a new bipartisan path for health insurance reform––or result in one incredible implosion of coverage if the Democrats didn't cooperate.
Either way, Obamacare is over.

The big stakeholder lobbies––insurance companies, hospitals, pharma, and doctors, will all be seen by the Trump administration as having been collaborators with the Democrats to pass this law in the first place. As a result, their organized lobbies will have far less to say this time. Insurers in particular, some CEOs were big cheerleaders when the law originally launched, are in a particularly difficult spot in this regard.

For victorious Republicans, Obamacare may well be the one thing that represents what the Obama years have stood for and therefore needs to be dismantled sooner rather than later.

Trump and Pence repeatedly made it clear that Obamacare would be repealed and replaced. They now have a mandate to do it and their supporters expect results. No Republican is going to stand in front of this freight train.

But, there is much more to consider here. The Obamacare exchanges are now in an underwriting free fall––how much worse will this election make things before Republicans address it? Will carriers begin to pull out in increasing numbers not wanting to be the last haven for a worsening pool? How can anything bipartisan be accomplished given the stark ideological differences between Democrats and Republicans on the health care issue? More on all of this later––it is now 3 am!

To say it is a new day in Washington, DC may be the understatement of them all.


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