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Hard truths about Obamacare

AS WASHINGTON REPUBLICANS scramble to keep their Obamacare repeal hopes alive, today let’s dispense with some lies, myths, and misplaced notions that have marked that debate.

For starters, the ACA is not failing. President Trump, of course, wants you to think otherwise. That’s why he keeps referring to the “dead carcass of Obamacare” and suggesting that the law will “crash and burn” absent federal action. So do House Speaker Paul Ryan and Senate majority leader Mitch McConnell.

But here’s what the well-regarded analysts at the Congressional Budget Office just wrote in analyzing the fate of the ACA’s health insurance markets if the current law stays in place: “The subsidies to purchase coverage, combined with the effects of the individual mandate, which requires most individuals to obtain insurance or pay a penalty, are anticipated to cause sufficient demand for insurance by enough people, including people with low health care expenditures, for the market to be stable in most areas.” As to insurance market failure, CBO does note that “a small number of people live in areas of the country that have limited participation by insurers in the nongroup market under current law.”

So: We have a national law that will continue to work overall, but which has some problem spots. That frames the real choice here. It is not, as Trump, McConnell, and Ryan would cynically lead the American people to believe, between repealing the ACA or coping with impending disaster. Rather, it is between repealing the law and repairing it.


On to a second truth: Despite what Trump promised on the campaign trail, there’s no way to provide health care that is much better, much cheaper, and that keeps everyone covered.

After all, we have now seen two putative Republican attempts to square that circle. The House bill would result, over a decade, in an additional 23 million people without health coverage, according to the CBO. The Senate’s offering would mean 22 million more uninsured.


Now, a substantial portion would be uncovered by choice. Many of those would be the so-called young invincibles, currently healthy young people who don’t believe they need insurance and who, without the individual mandate (and penalty), wouldn’t buy it.

But whether they anticipate them or not, young people do have health care needs. If they lack either insurance or the means to meet their bills, then those expenses are absorbed by hospitals or clinics or doctors — and passed on to everyone else in one form or another. Nor is this is a zero-sum generational game. Young people will eventually grow older, and when they do, they will benefit from the same system they are helping subsidize today.

Next up, Medicaid mythology. Don’t be deluded into thinking you can reduce Medicaid spending by almost $800 billion over a decade and, simply by giving governors more flexibility, somehow provide roughly similar health care for a roughly similar population. Yes, with added flexibility, states can stretch resources somewhat. But it will be all but impossible to keep the coverage for the ACA’s expanded Medicaid population once the higher ACA reimbursement for that cohort is phased out.

Here’s what is really afoot: Congress wants to cut federal Medicaid spending — which would clear up revenue space for tax cuts — but then leave it to governors to reduce the health care that that federal spending pays for and the population it covers. No wonder, then, that Republican governors are raising objections.


Again, the real choice here is repeal or repair. Interestingly, McConnell himself recently warned his caucus that if the Senate bill fails, Republicans will be forced to work with Senate Democrats on health care. Which would mean fixing rather than deep-sixing the ACA.

All that’s required is for a few Republican moderates to stand firm and say: Mend it, don’t end it.

Scot Lehigh can be reached at lehigh@globe.com. Follow him on Twitter @GlobeScotLehigh.