Can We Get Back to Kansas, Toto? If the Affordable Care Act is Repealed, Then What?

Ever since the United States Supreme Court ruled in the 2012 Sebelius decision that requiring individuals to purchase health insurance was constitutional, opponents have vowed to repeal the Affordable Care Act (ACA, or, as more popularly known, Obamacare). Even after the 2015 King v Burwell decision, when the Court upheld government subsidies underwriting premiums in states that had not established an insurance exchange, demands for repeal continued.

As the 2016 election appears on the horizon, it seems appropriate to engage in a little “what if” speculation. What if Republicans capture 1600 Pennsylvania Avenue, while retaining control of the House and Senate? Will the GOP really move to pull the plug on President Obama’s signature legislative accomplishment? What will they replace it with? More importantly, how do they do so without creating utter chaos?

A visit to the GOP website finds a lot of complaints hurled at “Obamacare”, and calls for its repeal, but little in the way of specifics. In order to get a feel for what a post-ACA world looks like to Republicans, you have to revisit the Party’s 2012 Platform.

The Platform defines healthcare as an individual responsibility, and claims that chronic conditions, often the result of poor lifestyle choices, account for 75% of the nation’s medical spending. It supports fostering personal responsibility, increasing preventive screenings, and providing coverage for mental health issues. The plan envisions three pillars on which to build a legislative agenda.

Return states to a regulatory role in local insurance markets and caring for the needy. Congress would block grant Medicaid funds and other payments to the states to administer as they see best. Funding and subsidies for abortion would be banned. There would be limits to federal requirements re Medicaid and private insurance, and states would  be urged to show similar restraint in issuing their own regulations. Assistance would be provided in resolving issues with risk adjustment and re-insurance to all patients, including those with pre-existing conditions.

Achieve a free market in healthcare. Allow individuals and businesses to form purchasing pools for health insurance. Cap non-economic damages in medical malpractice lawsuits. Enforce price transparency for medical costs, so consumers could easily compare prices between different providers.

Provide choice in healthcare. End tax discrimination between individual and group purchases to break the chains that link employment and health insurance coverage. Allow individuals to purchase health insurance across state lines. Promote private financial resources for healthcare expenses, such as Health Savings Accounts (HSA). For the nation’s elderly, keep patients out of institutions by making home care a priority in public policy.

So, the political opposition does have a plan, and one that’s been around since the 2012 presidential campaign. One might wonder why the Romney/Ryan ticket didn’t spend more energy promoting it, at least until one remembers Romneycare.

President Obama and other Democrats constantly worked the refrain that the ACA was patterned after then-Massachusettes governor Mitt Romney’s health insurance reforms in The Bay State in 2006. They were mostly on target, especially as regards expanding coverage, subsidizing premiums, and mandating the purchase of health insurance. Candidate Romney countered that his reforms were enacted in only one state, not forced on the entire country, but his explanation never gained traction, even with the GOP faithful. Obamacare, the issue that flipped the House of Representatives to Republicans in 2010, and ended the careers of several US Senate Democrats, sat on the shelf during the 2012 presidential election. What should have been a powerful campaign advantage became a liability for the Romney candidacy.

Because the Republicans’ commitment to their alternative was never battle-tested, just how prepared the GOP is to actually implement their plan is unknown. What type of timeline would be required to move from Party Platform to law? Which Congressional committees would be tasked with writing legislation? Once legislation is signed into law, how will the switch be accomplished? Most importantly, are the architects of the Republican proposal confident their plan will actually work?

The country might be better served if the GOP follows a two-tiered approach to health insurance reform. One track should certainly begin strategic planning to prepare for life after the Affordable Care Act. It will serve no one’s interests if, on day one of a Republican Administration, the first words the new president utters to Congressional leaders are, “What do we do now?” The GOP also needs to be transparent about the planning process, so potential supporters aren’t panicked by Democrat campaign ads predicting death and disaster if Obamacare is repealed. The entire process need not be dumped on the electorate, but reassurances should be made that no individual or group will be hung out to dry when repeal takes place. Here is where the GOP needs all hands on deck, whether they are current office holders, candidates, or party officials. In this era of candidate-centered elections, the one area where party discipline must be enforced is the issue of repeal and replacement of Obamacare. If Republicans take multiple positions on an alternative to the current law, the message will become so diluted as to be meaningless. For a change, the GOP needs to speak with one, coherent, confident voice.

A second, but equally important task for the GOP is to analyze what changes to the current law would lessen its impact on both those insured and their healthcare providers. What can be done NOW to reduce overzealous regulation, put more control in the hands of patients, protect doctors and hospitals from arbitrary cuts in Medicare/Medicaid reimbursements, and roll back built-in tax increases? Republican lawmakers and candidates could build credibilty with voters if they demonstrate themselves well versed in the complexities and shortcomings of a government-run health insurance system. It would be wise to consider what a Secretary of Health & Human Services, appointed by a Republican president, could accomplish with the flexibility accorded the Secretary in many provisions of the Affordable Care Act. In politics as in war, it never hurts to have a fallback position in case the unexpected happens, as it often does.

So, yes, Toto, we can get back to Kansas. The question is, what will Kansas look like when we get there?