From the beginning, the cries of "repeal Obamacare" - cries that started before the thing was even passed - made no sense. "Repeal Obamacare" has always had an air of exactitude that betrays how little its opponents understand about the bill, or for that matter healthcare policy, at all. Which is why the expanded "repeal and replace" mantra, never mind the farce now playing out in Congress, is both stupid, and dangerous.
You can't replace something with nothing, the saying goes, and yet that is, very much, how Republicans are approaching health policy. The ACA is a flawed, messy piece of legislation that no one can, or should, entirely love. But those real, practical problems within the ACA are nothing like the visceral antipathy of opponents who long ago gave up on trying to respond thoughtfully to the issues raised in healthcare reform.
If Republicans succeed - and on some level that's always a distinct possibility - the current bill is obviously disastrous: millions losing health insurance, problems around delivery of care will increase, costs will once again spiral out of control (to say nothing of the pointless windfall of tax cuts for the very very wealthy). Conservatives have no answer to these concerns because, as I've tried to point out for years to anyone who'd listen, the right has little or no serious expertise in healthcare policy, or for that matter, policy more generally. They have continuously thrown buzzwords and catch phrases where a policy should be: "free market solutions," "patient choice," ""bottom up, not top down." These terms are meaningless. And the nonsensical bill they threw together, in desperation, shows just how thin their thinking on the topic really is.
For one thing, this isn't repeal. The bill literally amends the Affordable Care Act, which alone may be a deal killer that even a majority in the House can't accept. Second, as long expected, the bill hedges on dealing with "popular" provisions of the ACA: the "stay on your parents plan til 26" option for children, the protection for preexisting conditions (though weakened), even, interestingly, a refusal to flat out kill the expansion of Medicaid, which for anti-poverty conservatives should have been an easy lift.
More importantly, conservatives betray their failures by wilting at every turn when hard choices come up - the ACA, as it turns out, is a complicated fabric of interlocked pieces where pulling on one thread causes the whole thing to unravel. I'm not sure even many of its supporters realized how intricate the construction has turned out to be. Pretty much any and every move conservatives have made has revealed a simmering mess just waiting to blow up in their faces - from trying to kill its financing to removing the insurance mandates to "bending the cost curve"... Conservatives have been forced back to the ACA because its basic premise - retaining the guarantee of employer based health insurance - underpins even their disjointed approach to a solution.
Once again here's the real point: if you use employment as the basis for insuring people, you have to provide solutions for people who don't fall under the defining criterion. That is, you have to deal with retirees (Medicare). You have to deal with people self employed or freelance or otherwise outside conventional employer-employee models of work (the exchanges or the individual market). And you have to deal with people who are unemployable or unable to be employed, such as the poorest and least educated (Medicaid and disability). This is the problem, and there really aren't a lot of great answers. There never were. The only solution is to spend the additional money to provide the options to the people who otherwise can't afford access to care. And fundamentally, the debate we're having isn't about the buzzwords about markets, and freedom and mythical choice: it's the basic, practical fact that the right simply wants to do less and have it cost less and damn the people who get hurt in the process. That's not a policy - it's the abdication of policy for nothing more than the monetary gain of a select few.
I've resisted wading into the weeds of what we're calling a "healthcare debate" partly because no one should be giving the right the cover of taking these proposals seriously as policy. They're not, and they shouldn't be. Until the conservative right can own up to its realities and face the problems they're trying to avoid by any means necessary, this isn't any kind of a healthy, productive conversation. Getting lost in their sea of silly tax credits, cuts to Medicaid (never mind their long desired death blow to the program entirely, a/k/a "block grants"), and reverse engineered regulatory changes is a fool's errand. The choice is much more simple, the terms especially stark - we can wreck the progress we've made increasing access to insurance and care, or we can deal with the problems we actually have. The rest is nonsense.
The sad fact is that the real failure of the ACA, still, is the failure to educate the public, the media and the political class about the realities of healthcare in the US. Conservatives get away with their falsehoods and fabrications and fantasies of free markets because few people arrive at the discussion armed with the information needed to confront them with facts and knowledge to refute their claims (this, sadly, applies to a number of other discussions, like education). Absent that information and awareness, it's easy as conservatives do, to claim a "death spiral" in insurance, to make hay out of the meaningless "choose your doctor" arguments, and on and on. The Know Nothings triumphed in November, and "repeal and replace" is the triumph of their crazed ambitions. Party on. If we're lucky, the best we can hope for is their complete failure.
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