Is Obamacare toast?
November 9, 2016 2:02 AM   Subscribe

Just how easily can Republicans repeal Obamacare? Can the repeal be fought in court? Can the repeal be drug out until the next 2020 election? Trump's promise to replace it is obviously smoke and mirrors, but what would he replace it with if he followed through? Lastly, is there a hope that some states might fight to keep some form of health coverage for their poorest residents? Yes, I am deeply worried.
posted by Beholder to Law & Government (16 answers total) 19 users marked this as a favorite
 
This will depend on two things:

1) Do Republicans nuke the filibuster.
2) Do Democrats keep at least 41-42 seats in the Senate in 2018.

I don't think we know the answer to those. I tenatively lean towards "no" on #1 though others will disagree. Don't know about #2 yet.
posted by Justinian at 2:16 AM on November 9, 2016


Re #2, it's rare for the president's party to gain seats in midterm elections -- I think it's happened three times since the Civil War -- though Dem turnout does tend to be lower.
posted by en forme de poire at 2:19 AM on November 9, 2016 [1 favorite]


They have the House and the Senate, so they can and will repeal it; the process, barring a successful fillibuster, is straightforward. Likeliest replacement is Ryan's plan to evolve Medicare to a voucher system.
posted by DarlingBri at 2:23 AM on November 9, 2016


Well that's the question; Democrats clearly have the votes to filibuster through 2018. The question is post-2018 and whether the Republicans nuke the filibuster.

This is also something I'm very worried about Beholder. I don't think anyone can give you a solid answer right now. Things are pure chaos. Wish we could give you more reassurance.
posted by Justinian at 2:25 AM on November 9, 2016


[One deleted. Sorry, but Ask Metafilter really isn't a space for open-ended back and forth discussion, but rather is a concrete Ask Question / Get Answers venue. If folks have fact- or info-based analysis that can help, that's fine, but extending the question and asking for guesses from people isn't workable here.]
posted by taz (staff) at 2:59 AM on November 9, 2016


O-Care, as we know it, is toast come January. They'll have to let it run through 2017 because we're already in the enrollment period. That gives them a year to devise something, if anything, to replace it. The easy thing would be to go back to the pre-O-Care system, but hospitals might balk at that as their emergency rooms were being used as primary care by the poor, and not getting much reimbursement for it.

As for the states...I can see California keeping a DIY system for the poor going, but most other states simply don't have the funds, or the will, to do anything.
posted by Thorzdad at 3:26 AM on November 9, 2016 [2 favorites]


It's not realistic to just repeal the whole ACA. I suspect parts of it will be though. Probably see a trend back to the way things were pre-ACA than a wholesale replacement.

There will likely be attempts to make big changes to Social Security, Medicare, Medicaid also. See Paul Ryan.
posted by LoveHam at 4:08 AM on November 9, 2016 [1 favorite]


The short answer is, we don't know yet what will happen.

As I've said several times in the political threads, the biggest obstacle to legislative repeal is probably the fact that insurance companies and medical providers are not going to want to see the insurance landscape changed so drastically, just a few years after the ACA went into effect. It's a complicated industry with (as we all know) a complicated payer system and big changes out of nowhere would mess up the system in ways almost impossible to predict.

That being said, Republicans might just push through a bare repeal with no replacement, if they can't decide on how to replace (and they haven't been able to in 8 years, mostly because there's not really any way to replace it in a small-government direction). That would lead to real chaos in the individual insurance market. We'd be back to the pre-Obamacare days, and there would be much less transparent and probably crappier insurance, which might or might not be affordable and which could discriminate against people with pre-existing conditions. If Republicans tried to repeal the parts they don't like (the individual mandate, regulations on what insurance plans must cover) but keep the requirement to cover pre-existing conditions, insurance companies would probably stop offering insurance altogether or offer it at very high cost.

The other danger is that authorization for funding might not happen. This would impact Medicaid, as the federal government is currently funding the lion's share of expanded Medicaid and would mean that low-income folks would lose insurance. If Medicaid is not funded, I'm not sure how long it would take for people to technically lose coverage, but I think probably it would become clear to providers that Medicaid cannot pay its bills and they would have to stop accepting patients enrolled in it. Premium tax credits might be a bit more difficult to unravel since they're enshrined in the law and I think you'd actually have to repeal the ACA to get rid of them. But depending on how exactly the mechanisms work by which the federal government advances the tax credits and sends them to insurers (subsidizing premiums for many lower to middle-class Americans), people might be on the hook to pay the full premium and then get the tax credits back as a lump sum on their taxes. Which many people would be unable to afford to do.

What Republicans have promised to do is to repeal the laws banning insurance from being sold across state lines, which, as far as I understand, basically means that some state will win a race to the regulatory bottom and end up the place where pretty much all the insurers operate out of, so we'll end up with shitty and confusing insurance that has all kinds of loopholes and such -- the regulations requiring a set of comprehensive benefits will probably be relaxed or totally thrown out the window, as I mentioned above.

The ACA also provided much more funding for federally qualified health centers, which are an important part of the medical safety net. We (I work for an FQHC) are required to take low-income uninsured patients on a sliding-fee basis and are compensated in large part by direct federal funding and Medicaid payments. So if those funding sources are slashed, at some point we won't be able to keep the lights on anymore.

It is grim and heartbreaking. I've been involved in ACA outreach work for three years, and I can't believe all the hard work so many people have done to try to help people connect to the medical care they need in this time might be wiped away. Also, I really like my job and would be sorry to lose it -- I don't rely directly on an ACA-related grant anymore, but at this point I have to consider that the whole FQHC system might not be there anymore.

If bad things happen, I expect that some of the wealthier blue states might try to mirror some of the ACA system. Probably the West Coast states, maybe New York, maybe some of the New England states. It'd be a difficult thing to do though, there are a lot of moving parts. Colorado had a referendum yesterday on single-payer but it got its ass kicked.

Head down and carry on for now. The 2017 plan year is already in motion and I'm assuming nothing will happen to that. Then we will see if the new year will be worse than 2016 has been.
posted by tivalasvegas at 5:03 AM on November 9, 2016 [28 favorites]


I'm expecting a bill that will repeal some provisions and be proclaimed to be the end of Obamacare. I don't think anyone can say what will be left, but maybe quite a lot. I imagine the Republicans are most interested in getting rid of the subsidies, both Obamacare premium subsidies and Medicaid subsidies.

Before OCare, some states were much more generous about Medicaid than others. OCare did not lower the percent of uninsured very much in Massachusetts or Connecticut because they were already taking good care of their citizens. I expect them to pick up the ball again as best they can.

I don't expect a significant replacement. It's hard to do much without spending lots of money.

Health insurance remains very much a state regulated field. Just because (e.g.) a Texas company gets Federal permission to sell insurance in Connecticut doesn't relieve them of the obligation to meed Connecticut requirements. Many of the big companies (e.g. BlueCross/BlueSheild) are multistate insurers via complex corporate structures. Working for a Connecticut company in Connecticut, I was once insured via my employer by BC/BS of California. Anyway, I think the promise of interstate insurance is largely a chimera. And any attempt will result in a ton of litigation.
posted by SemiSalt at 5:30 AM on November 9, 2016 [10 favorites]


2017 is ok because contracts already in place. 2018 will probably be ok because of looming 2018 midterm elections. that leaves 2019... but then there's the 2020 presidential election
posted by youchirren at 11:22 AM on November 9, 2016 [2 favorites]


Previous attempts were a straight-up repeal effective 180 days from enactment

bill text

presumably, that would affect policies at renewal time.
posted by osi at 1:33 PM on November 9, 2016 [1 favorite]


It's interesting because many of the Republican constituents want to keep their Medicare etc. So it's not going to be as simple as "destroy the safety net". But the parts of the safety net that aren't aimed as much at their constituents are probably in for a creaming.

The plans signed up for at open enrollment this year will last through the year, though.
posted by Lady Li at 3:15 PM on November 9, 2016 [1 favorite]


The most recent attempt that got all the way to Obama's desk seems like it would have been effective after 2017, for the most part. This is likely close to what they will pass, which means 2017 and 2018 are likely safe.

HB 3762
posted by zrail at 4:51 PM on November 9, 2016


Note that the Republicans pass this stuff through reconciliation which means they can only repeal the monetary portions of Obamacare and not most of the regulatory ones.

What that means is they can eliminate the penalty for not having insurance, eliminate grants to States to help cover people, eliminate subsidies to individuals to help them pay for insurance, and so on. But they can't eliminate things like the pre-existing condition requirement with reconciliation.

This could set up a terrible situation where the Republicans repeal subsidies and grants and penalties but not the popular stuff. But that means a death spiral is almost inevitable as healthy people drop out (no penalty!) and rates are raised, more people drop out, rates are rasied more, and so on.

I've read some arguments that in such a situation we would actually end up with more uninsured people than there were when Obamacare kicked in. It would in many senses actually be worse than what we had pre Obamacare.

So, yeah, the answer is still we don't actually know, Beholder. Parts of Obamacare can be repealed with a bare majority if they deal with the budget. Parts can only be repealed over a filibuster. The Republicans may repeal the budgetary parts, which leaves Obamacare unsupportable, and then present the Democrats in the Senate with the choice of cooperating with a full repeal of Obamacare or refusing to cooperate and leaving a "worst of both worlds" situation.
posted by Justinian at 7:10 PM on November 9, 2016


Thanks for the answers everyone.
posted by Beholder at 6:50 AM on November 10, 2016


Justinian - I see no reason to expect the filibuster to hold. So, I think they will aim for something that -- while it may be devastating to a lot of people (especially poor people, because expect to see Medicaid rolled waaaaaay back) -- at least isn't a death spiral. But, we'll see.
posted by rainbowbrite at 9:40 AM on November 10, 2016


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