Repeal and replace isn’t dead yet

Don’t kid yourself. We haven’t heard the last of repealing and replacing Obamacare.

The GOP’s latest attempt to undermine the law failed because three Republicans, the bare minimum, had enough sense to oppose legislation that would create chaos throughout one-sixth of the U.S. economy. The Graham-Cassidy bill would have given every state just two years to completely revamp their Medicaid programs and individual insurance markets with an estimated $1 trillion less money over the next decade.

According to the best available estimates (the usually reliable Congressional Budget Office could only give directional estimates for what 50 state legislatures might do), tens of millions of Americans would have lost insurance coverage. Hundreds of thousands of healthcare workers would have lost their jobs. In states with GOP-controlled statehouses (Republicans now have 33 governors and control 32 legislatures), insurance companies would have become largely deregulated. People with pre-existing conditions in many of those states would get slapped with soaring rates. Bare-bones coverage with huge out-of-pocket expenses would become the norm in many regions.

Despite protests from organizations representing every major healthcare constituency, each GOP senator save three were willing to sign on to the bill.

As soon as Senate Majority Leader Mitch McConnell admitted defeat for a second time, the bill’s architects vowed to attach it to the budget bill that must be approved to avoid a government shutdown. Conservative hardliners took to the airwaves to call on the Trump administration to cut off its monthto-month support of the cost-sharing subsidies that allow insurers to lower out-of-pocket expenses for the poorest Americans who buy exchange plans.

Given the fundamentally conservative nature of Obamacare—it relied on private insurers and Medicaid to expand coverage, not single-payer or other more radical measures—one has to ask why the GOP remains fixated on destroying something that has worked fairly well. The uninsured rate is in single digits; and overall healthcare spending, rising at its slowest pace since the 1990s, enabled the government to spend nearly half a trillion dollars less than originally expected on Medicare, Medicaid and subsidies for the uninsured.

The easy answer is that it is all about the increasingly nasty infighting on the GOP right. You can’t scream “repeal and replace” for seven years and then fail to deliver.

But something deeper is at work. In a must-read article in the latest New Yorker, Dr. Atul Gawande returned to his native Athens, Ohio, a college town on the edge of Appalachia, to talk about health reform with local residents. He provocatively began with this question: “Is healthcare a right?”

Many of the people he spoke with had serious healthcare needs. Those with employer-provided health insurance struggled to pay their copays and deductibles. They repeatedly denounced people on Medicaid, saying they “just don’t work. They’re lazy.”

The idea that Medicaid is filled with able-bodied people unwilling to work has become a staple of the current healthcare debate. Yet, before the Medicaid expansion, less than 20% of people on Medicaid were able-bodied adults, neither aged or disabled.

Gawande notes near the end of his article that “the ACA postponed reckoning with our generations-old error of yoking healthcare to our jobs—an error that has made it disastrously difficult to discipline costs and insure (sic) quality, while severing care from our foundational agreement that, when it comes to the most basic needs and burdens of life and liberty, all lives have equal worth.

“The prospects and costs for healthcare in America still vary wildly, and incomprehensibly, according to your job, your state, your age, your income, your marital status, your gender and your medical history,” he wrote.

As long as that’s the case, unscrupulous politicians will be able to exploit the resentments those inequities breed, and pit one group of Americans against another for their own electoral advantage. Graham-Cassidy may be dead, but repeal and replace lives on.