Michael A. Cohen

How to save Obamacare? Repeal it

Demonstrators stand outside a hotel before former South Carolina Senator Jim DeMint speaks at a "Defund Obamacare Tour" rally in Indianapolis on August 26, 2013.
Demonstrators stand outside a hotel before former South Carolina Senator Jim DeMint speaks at a "Defund Obamacare Tour" rally in Indianapolis on August 26, 2013. REUTERS/Nate Chute/File

Republicans have put themselves in quite a bind in their war against Obamacare. For political reasons they desperately want to repeal it, but don’t want to bear the consequences of what happens when they do. But here’s a possible solution to their problem and it’s one that Democrats should not only support, but actually propose: Fully repeal every word of Obamacare.

But, there’s a catch – and it’s a big one.

Congress should pass a repeal bill that goes into effect in three years. But if they fail to come up with a replacement measure in that time, Obamacare would remain in effect. A further three-year extension could be written into the bill that would give legislators another bite at the apple. But if they fail again, Obamacare would stay the law of the land.


The beauty of this idea is that it’s quite similar to what Republicans are currently proposing to do — namely, scrap Obamacare now with the repeal to go into effect in three years. The problem is that this repeal would occur with no clear replacement for it in three years and, with Democrats able to filibuster a Republican bill, no clear political path to pass one.

This would create massive uncertainty in the individual insurance market and many insurers would likely choose to abandon it. Millions could potentially lose their insurance coverage, premiums would skyrocket, and we’d see a return to the utterly inadequate pre-Obamacare individual market. For obvious reasons, Republicans would rather avoid this disastrous political outcome. Repeal-ish could take away some of the uncertainty, since insurers may conclude that no replacement bill will ever be passed and if one is, it will do so with bipartisan support, thus providing them with long-term predictability about the insurance market. In short, they’d have reason to hold out a bit longer before abandoning the market altogether.


Why would Democrats go along with an idea that would basically do away with, if symbolically, the greatest policy achievement for the party in the Obama years? Because it’s the best possible way to prevent millions from being hurt by repealing the legislation. Democrats could sit back and do nothing while the individual market collapses and then let Republicans reap the whirlwind. But preserving the outlines of Obamacare and preventing mass disruption in the insurance market must be the party’s number one priority. Surely there will be some liberals outraged at congressional Democrats going along with a repeal of Obamacare, but that’s a political price that most Democrats should be willing to withstand.

What do Republicans have to gain? The answer is obvious: It allows them to take a political victory lap for repealing Obamacare without facing a backlash from consumers. Republicans have said repeatedly that Obamacare is a disaster, but you can’t replace something with nothing, and this move would put the pressure to come up with “something” where it belongs — on Republicans.

Certainly there will be some conservatives who would see this measure as a gimmick that doesn’t guarantee Obamacare’s demise, since Democrats would have little incentive to work with Republicans on a replacement plan. But that would actually play to the GOP’s political benefit. If no replacement legislation can get past a Democratic filibuster, it would give the GOP a political issue to use against Democrats in Senate elections in 2018 and 2020. “Vote out Democratic Senator ____ who is defending Obama’s failed health care plan.”


But the more important reality is that most Republicans hate the idea of Obamacare more than they hate it in practice. There are few Americans who truly want to see health care subsidies cut for middle-class families, Medicaid ripped away from poor Americans, or people denied coverage because of preexisting conditions. Would congressional Republicans rather upset GOP voters who want Obamacare to be dead and buried or face the political consequences of being blamed for premiums spiking and millions losing coverage? Either way, there could be a political backlash. But the former is undoubtedly better for them than the latter, especially since congressional Republicans and President Trump could run around the country bragging how they finally repealed Obamacare.

What about the insurance companies? This is the tricky part, and there’s no guarantee that they won’t still flee the individual market. But here is where Democrats and Republican could get creative and, in the process, do a solid for health care consumers.

First, Republicans could pledge to end a current lawsuit wending its way through the federal courts that removes cost-sharing subsidies that insurers currently are required to provide to poorer customers. Indeed, the insurance industry has already made clear that stopping these subsidies from going away is their top near-term priority.

Second, they could offer financial incentives to the industry to stick around the exchanges — an idea that House Republicans have already floated. Third, Congress could look for ways to strengthen the exchanges and make them more competitive. The obvious steps — like increasing the penalty of the individual mandate or increasing subsidies for customers — are likely political nonstarters. Congress could require insurers who sell individual insurance plans outside the exchanges to also sell them in the exchanges. They could also require those who currently sell Medicare Advantage plans to also sell an individual market plan. These would be heavy political lifts too, but they would create more competition in the Obamacare exchanges and perhaps even lower prices. In repealing Obamacare, but not really repealing it, Republicans could even find a way to take credit for fixing the law’s problems.


There are other questions to consider. For example, what constitutes an Obamacare replacement plan? That would have to be worked out, but one could imagine language in which any replacement to Obamacare would have to be (a) deficit neutral, (b) not lead to an increase in the number of uninsured, and (c) not lead to increase in health care costs. The Congressional Budget Office could be the arbiter of whether a replacement bill meets those requirements — or perhaps Congress could appoint a bipartisan commission to decide.

To be sure, this is far from an ideal plan. It’s a political solution to a political problem rather than a well-thought-out policy for strengthening the US health care system. But, Congress has a long and illustrious track record of kicking the can down the road. Conditional repeal is the least worst solution to a problem that Republicans created in pledging to get rid of Obamacare with no idea what to do the day after. It would give them a short-term political victory while ensuring that the millions who have benefited from Obamacare will not be hurt. It’s an idea that both Democrats and Republicans could begrudgingly accept — and that’s about the closest we’re likely to come to a win-win in Congress these days.


Michael A. Cohen’s column appears regularly in the Globe. Follow him on Twitter @speechboy71.