Complacency could put an end to the ACA

Paul Krugman says public attention is no longer on heath care and Republicans have come up with another plan.

I haven’t yet read Hillary Clinton’s “What Happened,” but it seems pretty clear to me what did, in fact, happen in 2016.

These days, America starts from a baseline of extreme tribalism: 47 or 48 percent of the electorate will vote for any Republican, no matter how terrible, and against any Democrat, no matter how good. This means, in turn, that small things — journalists acting like mean kids in high school, ganging up on candidates they consider uncool, events that suggest fresh scandal even when there’s nothing there — can tip the balance in favor of even the worst candidate imaginable.

And, crucially, last year far too many people were complacent; they assumed that Trump couldn’t possibly become president, so they felt free to engage in trivial pursuits. Then they woke up to find that the inconceivable had happened.

Is something similar about to go down with health care?

Republican attempts to destroy Obamacare have repeatedly failed, and for very good reason. Their attacks on the Affordable Care Act were always based on lies, and they have never come up with a decent alternative.

The simple fact is that all the major elements of the ACA — prohibiting discrimination by insurers based on medical history, requiring that people buy insurance even if they’re currently healthy, premium subsidies and Medicaid expansion that make insurance affordable even for those with lower incomes — are there because they’re necessary. Yet every plan Republicans have offered would do away with or undermine those key elements, causing tens of millions of Americans to lose health insurance, with the heaviest burden falling on the most vulnerable.

All this should be clear to everyone by now. So you might be tempted to assume that no plan along these lines can possibly pass, let alone one that, if anything, looks worse than what we’ve seen so far. But it’s precisely because so many people assume that the threat is behind us, and have turned their attention elsewhere, that health care is once again in danger.

The sponsors of the Graham-Cassidy bill now working its way toward a Senate vote claim to be offering a moderate approach that preserves the good things about Obamacare. In other words, they are maintaining the GOP norm of lying both about the content of Obamacare and about what would replace it.

In reality, Graham-Cassidy is the opposite of moderate. It contains, in exaggerated and almost caricature form, all the elements that made previous Republican proposals so cruel and destructive. It would eliminate the individual mandate, undermine if not effectively eliminate protection for people with pre-existing conditions, and slash funding for subsidies and Medicaid. There are a few additional twists, but they’re all bad — notably, a funding formula that would penalize states that are actually successful in reducing the number of uninsured.

Did this bill’s sponsors — Lindsey Graham, Bill Cassidy, Ron Johnson and Dean Heller — manage to get through months of health care debate without learning anything about the issue? Maybe. But surely the rest of the Senate, not to mention much of the public, has wised up about false Republican promises. A huge majority of voters, almost 2-1, consider it a good thing that previous attempts at repealing and replacing Obamacare failed.

Yet there is a real chance that Graham-Cassidy, which is similar to but even worse than previous Republican proposals, will nonetheless become law, because not enough people are taking it seriously.

As in the presidential election, we start from a baseline of extreme tribalism, in which 48 or 49 Republican senators will vote for anything, no matter how awful, that bears their party’s seal of approval. To make a bill the law, its sponsors only need to win one or two more votes.

The main reason Republican leaders couldn’t do that on previous health bills was public outrage and activism. Letters and phone calls, demonstrators and crowds at town halls, made it clear that many Americans were aware of the stakes, and that politicians who voted to take health care away from millions would be held accountable.

Now, however, the news cycle has moved on, taking public attention with it. Many progressives have already begun taking Obamacare’s achievements for granted, and are moving on from protest against right-wing schemes to dreams of single-payer. Unfortunately, that’s exactly the kind of environment in which swing senators, no longer in the spotlight, might be bribed or bullied into voting for a truly terrible bill.

The good news is that for technical reasons of parliamentary procedure, Graham-Cassidy has to pass by the end of this month, or not at all. The bad news is that such passage is a real possibility.

So if you care about preserving the huge gains the ACA has brought, make your voice heard. Otherwise we may wake up to another terrible morning after.