Wednesday, January 18, 2017

A good day for the ACA

While there will doubtless be many shifts and turns in the battle over the ACA, the road to repeal has seemingly got steeper for Republicans in the last couple of days. Some good developments:

1) Trump blew in with his promises to cover everyone, with low deductibles, and to enact his magic replacement at the same time as ACA repeal. That would seem to make it harder for Republicans in Congress to proceed with repeal-and-delay.

2) The Congressional Budget Office, traditionally the arbiter of the fiscal viability of proposed legislation, did the Urban Institute one better and estimated that the repeal-and-delay bill Republicans passed in late 2015 (vetoed by Obama) would un-insure 32 million people in a decade.

3) Media coverage pretty universally noted that the Jan. 15 rallies reflected deep support for the ACA and stiff resistance to repeal from its proponents. The NYT's Robert Pear, generally caustic about the ACA, put it this way:

People who benefit from the law are flooding Congress with testimonials. Angry consumers are confronting Republican lawmakers. And Democrats who saw the law as a political liability in recent elections have suddenly found their voice, proudly defending the law now that it is in trouble.
4) For the first time in a while, a poll (from NBC) put ACA approval in positive territory. (I'd take NBC's "more popular than ever" with a grain of salt; Kaiser's monthly tracking poll has had the ACA in positive territory from time to time.)


5) Louisiana Senator Bill Cassidy told Bloomberg's Steven Dennis that he is dusting off and updating his previous ACA replacement plans (he has two, 2015 and 2016 versions), which do not repeal and therefore do not defund it. In some ways the 2015 plan (introduced when the federal ACA marketplace was under threat of defunding as the Supreme Court considered the King v. Burwell lawsuit) is very like the healthcare wonk fantasy escape hatch sometimes known as "superwaiver," in which states can choose alternative means to cover their citizens (which they can already do under comparatively tight federal oversight via the ACA’s innovation waivers). While Cassidy's 2016 plan models some pretty bizarre alternatives, putting Cassidy's approach in the current mix increases pressure on Republicans to do less harm than they've generally been vowing to do. Most notably, Cassidy would preserve ACA-level funding, or close to it, including for states that choose the plan's HSA-friendly conservative alternative.  Moreover, Susan Collins is working with Cassidy, along with Rep Pete Sessions, who co-sponsored the 2015 replacement bill.*

On the other side of the equation, Robert Pear's coverage of the CBO report includes a tidbit suggesting that Republicans may attempt to do replacement as well as repeal via budget reconciliation:
Republican congressional leaders are trying to put together a plan that culd pass muster with the Trump team and also win approval in the Senate under the fast-track procedures that would neutralize the threat of a Democratic filibuster.
Is it possible to pass replacement legislation via reconciliation? I would think reconstructing the markets (repealing ACA coverage rules) would require a lot of provisions that don't directly affect the federal budget, as reconciliation legislation must do. But maybe Republicans are preparing to declare that all such regulations affect the budget because they reshape the market and so determine federal outlays (via subsidies). And if the Senate parliamentarian doesn't agree -- fire him?

In any case, it wasn't that long ago that media was pretty much treating repeal as a done deal. No more. No one knows how this fight will play out, and ACA proponents have good cause to mount as powerful a defense as they can.

Proponents can also take a encouragement from the past. My prior post recalls that while the Tea Party got all the media attention in the fight to pass the ACA, massive grassroots advocacy from a huge consortium of progressive organizations won the day. That coalition is reconstituting itself now.

Update: Not to get punchy, Brian Beutler spotlights one disaster scenario among many: Republicans hold off on repeal but administratively sabotage the ACA marketplace, then blame the market collapse they've falsely asserted is in progress now on Democrats.
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* I've updated and clarified description of Cassidy's plans.

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