Long before Obamacare, the federal government had been subsidizing health insurance for scores of millions of Americans. The law expanded that subsidization to cover several million more people.
If that’s all it had done, it might have gotten some Republican support: Forty Republicans in the House and seven in the Senate voted to expand the Children’s Health Insurance Program in the first weeks of Obama’s presidency.
But the Obamacare law also, for the first time, made the federal government the chief regulator of health insurance. And these regulations are responsible for nearly all the uproar about the law. It’s the regulations that caused people to lose their health insurance, contrary to Obama’s if-youlike-it-you-can-keep-it promise. It’s the regulations that have led to high premiums for many plans. It’s the regulations that have undermined the viability of the government’s health exchanges.
Yet many Republicans, Philip Klein reports, are considering moving quickly next year on a bill to “repeal” Obamacare without touching its regulations. They hope that the Trump administration uses executive power to loosen those regulations subsequently. But many of the most problematic regulations — like the ones setting a ratio for the premiums that can be charged for the young compared to the old — are in the law itself, and cannot legitimately be modified that way.
The Republicans are thinking of leaving Obamacare’s regulations in place because they fear that a bill altering them would die in a filibuster. They are sure they can use a procedure for avoiding filibusters if they target only the law’s tax and spending provisions.
This course could cause the insurance exchanges, already in trouble, to collapse entirely. That’s because the Republican bill would scrap the individual mandate while keeping Obamacare’s requirement that insurers treat sick and healthy people alike.
The individual mandate exists because Obamacare’s architects understood that this requirement, on its own, gives healthy people a reason not to buy insurance: They can wait until they get sick and buy it. But the more that healthy people avoid insurance, the higher premiums will have to be — and as they go higher, even more healthy people will stop buying coverage. Insurance markets can’t work that way.
The Republicans to whom Klein talked are blasé about this possibility. If millions of people lose their coverage, these Republicans plan to say that the exchanges were already collapsing before they touched the law. It seems unlikely that the press will go along with this narrative, in part because many health-care experts, liberal and conservative, will tell reporters that it’s false.
What Republicans have not faced is that they don’t have the votes to repeal Obamacare. Calling a bill that doesn’t repeal Obamacare’s central provisions “repeal” is no escape from that dilemma.