Congress and the new president in a matter of weeks will repeal big parts of the Affordable Care Act, at least nominally, but what will follow that wondrous event will not be the contentment that Republicans have long promised, but even more political tumult. This time, Republicans will have to man the ramparts.
It may not reach the intensity of the 2010 congressional recess when Democrats futilely and poorly defended themselves against charges that by passing Obamacare they had taken away people's Medicare benefits, destroyed millions of jobs and businesses, ended doctor-patient relationships, endangered the health insurance of millions of people, caused medical spending to soar, signed the death warrants of frail grandmothers and sent the national deficit skyrocketing. None of that ever happened, but exactly the opposite, especially if you lived in Arkansas, and hostility to the law moderated.
Now, Republicans will be on the defensive and under pressure to find a way to avoid the loss of often life-saving health insurance for some 20 million Americans, nearly all of them working folks that Donald Trump said he was going to protect.
Not only that, but, depending on how Congress and the president configure the repeal, the national budget deficit will immediately reverse its downward course and soar once again. How will they explain and justify that? The nonpartisan Congressional Budget Office, now in the hands of Republicans, produced a study in September showing that Obamacare had steadily shaved the national deficit since it took effect and forecasting that the law's repeal would add some $137 billion to the deficit over the next decade, largely because it would restore high Medicare payments to providers and end payroll taxes and a surtax paid by people with very high incomes and taxes on insurance companies and makers of brand-name drugs and medical equipment.
Congress could stall the repeal of the taxes to keep the money flowing and avoid the exploding deficit, but ending Obamacare's taxes on the rich and drug manufacturers has been the biggest driver of the repeal movement. If nothing else, those have to go.
Republicans always promised that they would replace Obamacare with something better and find a way to keep some of the overwhelmingly popular parts of it, although none of the repeal bills carried provisions to replace or keep anything. Republican strategists say the actual end to the big features of the law — expanded Medicaid coverage for the working poor and private and often subsidized insurance for people who do not have employer coverage — probably will be postponed until at least 2019 and perhaps even later. That will give them time to draft a new plan to provide some form of coverage for those 20 million people that will not be called Obamacare or the Affordable Care Act. It also will stave off outrage before the 2018 congressional elections. They don't want a repeat of the 2012 and 2014 congressional elections, this time with Republicans on the receiving end of voter distemper.
The unexpected election of Donald Trump presents the congressional party with a dilemma. Two years ago, House Republicans sued in federal court to strike down the adjustable tax credits that form the basis of the Affordable Care Act. People with family incomes below 400 percent of the poverty line can get sliding federal tax credits to help them afford private insurance premiums. The D.C. Court of Appeals postponed the hearing on the appeal until February, after the election. Presuming that, unlike President Obama, President Trump will not send lawyers to defend the constitutionality of the tax credits, the Republicans' chances of winning the case in a now uncontested appeal go up. If they win the appeal, millions of working people could instantly lose their coverage, a crisis the party is not ready to confront. Congress might have to appropriate billions of dollars directly to the insurance exchanges to continue the coverage until they have a plan to replace Obamacare. How embarrassing.
No one watches the unfolding drama with more anxiety than Governor Hutchinson and forces in the Arkansas legislature from both parties who know what Obamacare has meant for the state's economy and specifically the state budget. A sudden or even prolonged demise of the health program will wreck the state's budget and legislative and gubernatorial tax-cutting ambitions, imperil community and state hospitals and stall the growth engine that the Medicaid expansion and premium subsidies created in 2013. The state's unemployment rate plunged to one of the lowest in the country.
Aside from the budget and human implications of ending medical coverage for 400,000 Arkansans, there is the little calculus of what happens if they suddenly are confronted with the knowledge of who their real political friends are?