The GOP’s health care follies

WASHINGTON, DC - JANUARY 04: (L-R) Sen. John Barrasso (R-WY), Sen. John Thune (R-SD), U.S. Vice President-elect Mike Pence, Sen. Roy Blunt (R-MO), Trump White House Chief of Staff Reince Priebus and Senate Majority Leader Mitch McConnell (R-KY) hold a news conference following a GOP caucus meeting at the U.S. Capitol January 4, 2017 in Washington, DC. Pence talked with the Republican Senators about repealing and replacing Obamacare during the first caucus meeting of the 115th Congress. (Photo by Chip Somodevilla/Getty Images)
Chip Somodevilla/Getty Images
Vice President-elect Mike Pence and Republican leaders held a press confererence on Jan. 4 after meeting to discuss the repeal of the Affordable Care Act.

After years of pointless votes to repeal the Affordable Care Act, congressional Republicans will soon have an opportunity to do so for real — with a strong likelihood that incoming president Donald Trump will affix his signature to their effort. What the GOP doesn’t have, however, is a credible alternative plan. During the campaign, candidate Trump promised that he would replace Obamacare with something much better and much less expensive, but which covers everyone.

In this new era of one-party governance, the GOP must be held to that standard. That is, quality health coverage that is universally affordable. Right now, there is no GOP road map for getting to that goal. Instead, the Republican plan is to repeal as much as possible of the ACA now, with a delayed deadline, and replace it with something else before that repeal takes effect.

In part, that strategy reflects this problem: Although they have bruited about a variety of ideas, Republicans do not agree on what their replacement health care plan should look like. But given their ideological predisposition, it’s almost inevitable that whatever substitute congressional Republicans arrive at will help considerably fewer people. After all, one of the main points of conservative opposition to Obamacare has been the expanded Medicaid coverage, which has brought health care to an additional 11 million people. (The refusal to expand Medicaid in most Republican states has meant that GOP governors and legislatures have denied health coverage to another 2.6 million who otherwise would have been eligible.)


Ending expanded Medicaid will mean yanking coverage from that population. And if the federal subsidies for moderate- and middle-income families are eliminated or scaled back, millions who get their health care coverage on the exchange may well find that comparable coverage is now out of reach. One way to make those plans cheaper, of course, is to offer less by way of coverage, which explains the Republican talk of a fallback plan that only covers catastrophic illness. But that clearly wouldn’t be better coverage than Obamacare.

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Another emerging GOP refrain is that what matters is not universal coverage but rather universal access to coverage. But if low- and moderate-income citizens can’t afford that coverage, then universal access is more a word game than a strategy for providing health care.

Some of the principal protections of the Affordable Care Act may well be doomed if the major parts are repealed, even if those protections themselves aren’t explicitly nixed. For example, without a requirement that everyone carry coverage, it probably won’t be possible to ensure that those with preexisting health conditions will be able to find affordable policies. There’s GOP talk of creating separate high-risk pools for the preexisting-condition population, with government subsidies to help lower the cost of premiums. Voters should understand, however, that such a move would simply swap one method of socializing those health costs — that is, by spreading them across the larger group of private-policy buyers — with another: taxpayer subsidies.

Meanwhile, as US Representative Richard Neal, the ranking Democrat on the House Ways and Means Committee, notes, the repeal-now-replace-later strategy could create chaos in the insurance markets. “It will,” Neal says, “allow some of the insurance companies to say, ‘If we don’t know what the certainties are, why don’t we just get out of the exchanges?’ ”

There will no doubt be reassurances aplenty about the GOP plan to come. But the American Medical Association has it exactly right. On Tuesday, the country’s most influential physicians’ group cautioned against the repeal-now-replace-later approach. Saying it was essential that the gains in coverage under the ACA be maintained, the AMA wrote that “before any action is taken through reconciliation or other means that would potentially alter coverage, policymakers should lay out for the American people, in reasonable detail, what will replace current policies. Patients and other stakeholders should be able to clearly compare current policy to new proposals so they can make informed decisions about whether it represents a step forward in the ongoing process of health reform.”


If the GOP goes forward with its current strategy, it will instead be asking the country to buy a pig in a poke. Buyer beware. Or, in this case, citizens must be wary — and make themselves heard.