The logic of ACA (and illogic of its repeal)

This Ron Brownstein piece is ostensibly about how Trump’s core voters stand to lose as much as anyone from an ACA repeal.  But what I really like about it is that it explains the logic of ACA (and the illogic– or at least, every person for themselves appeal– of the Republican alternatives) as well as anything I’ve read.  Very good stuff:

Though few subjects may seem more arcane than health-insurance regulation, these contrasting approaches illuminate a core philosophical divide between the parties. The ACA prizes solidarity: It is an intricately interlocked mechanism for sharing the financial risks of medical needs in two respects. First, it shares risk across generations—with today’s young subsidizing today’s old. Second, it spreads risk across any individual’s lifecycle: Under the law, people pay more for health coverage when they are young so they can pay less when they are old. “In many ways under the law the young and healthy are subsidizing the older and sicker on the theory that eventually all of us get older and sicker,” [emphases mine] said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University. “A key policy driver of the ACA is to pool risk as much as possible on the theory that will make coverage more affordable to a greater number of people.”

By contrast, the GOP plans all prize autonomy. They would allow individuals more choice in whether to buy insurance at all or what kind to purchase, and allow the healthy to pay less unless and until they have significant health needs. The price, in policy terms, for that flexibility is accepting wider divergence between the healthy and sick in both the availability and cost of care. Under the Republican plans, “There’s a scenario where people get a cheaper premium and they have more out of pocket cost sharing and more benefit exclusions,” said Christine Eibner, a Rand Corporation senior economist who studies health care. “And if they have a healthy year they look at it and say this is better. But then they could be in for a surprise if there is a catastrophe or they get really sick and they find something is excluded and the cost sharing is really high.”

Plenty more good explanation of how the ACA marketplaces work and what it would mean to end them.  Want to better understand how the ACA really works (and why repeal is such a bad idea), just read the whole thing.

This is what repeal looks like

CBO report out today.  Drum’s summary of the key points is good and succinct:

Senate Democrats asked for an estimate of what would happen if Obamacare were repealed. Here’s the CBO’s answer:

  • 18 million people would lose insurance. By 2026, that would increase to 32 million.
  • Premiums in the individual market would skyrocket, increasing 20-25 percent in the first year and about 50 percent by 2026.
  • Insurers would exit the individual market en masse. About half the nation’s population would live in areas with no individual insurers at all, rising to three-quarters by 2026.

That is inconvenient, isn’t it? This is what happens if you eliminate Obamacare but keep in place the ban on pre-existing conditions—which Republicans all say they support and which they can’t repeal anyway. Premiums would skyrocket, 32 million people would lose coverage, and insurers would abandon about three-quarters of the country.

This is what Republicans need to address with their “replace” plan. But they can’t do it and they know it.

How long before the Republicans just try to banish the CBO and replace it with the CRU (Congressional Unicorns and Rainbows) which would make their plans work out okay?

Democrats need to hammer and hammer and hammer on these facts above.  And hammer some more.

How Trump can have what he wants on health care

Donald Trump has said that with his health care plan, nobody will lose coverage, there will be better coverage, and it will cost less money.  Sounds impossible– yes?  Actually, only politically impossible.  Policy-wise, the entire rest of the developed world does this.  We are unique in paying so much for so little quality care.  The problem is that the rest of the world does this through more, not less, government involvement and regulation.  And we know how that goes over with Republicans.

Yglesias suggests that Democrats should offer a clear alternative plan.

Fortunately, a sound middle ground is available.

  • The version of the public option included in the House Progressive Caucus budget would reduce federal health spending by $218 billion over 10 years, by taking advantage of Medicare’s greater bargaining power.
  • Clinton’s campaign outlined three proposals to reduce premiums and out-of-pocket costs that the RAND Corporation assessed would reduce the ranks of the uninsured by a further 10 million while “decreasing average spending by up to 33 percent for those with moderately low incomes.”
  • Clinton’s benefit enhancements would cost $90 million, a small fraction of the $218 billion the public option would save.
  • The additional $120 billion or so could simply be allocated to the Medicare Trust Fund, contributing to further extending its life.
  • Last, while there is considerable debate as to the practical impact of Trump’s proposal to eliminate the “lines between the states” and establish a unified federal market in health insurance plans, it seems like an idea worth trying. In the context of a Republican repeal-and-replace plan, eliminating the “lines” would be a de facto total deregulation of the insurance industry. But relying on the Affordable Care Act regulatory minimums while allowing insurers to operate in as many (or few) states as they like seems desirable.

You could, of course, also throw some other favorite progressive ideas into the mix, like a Medicare buy-in for people over the age of 55 (though a good public option should make this unnecessary), steps to speed the approval of generic drugs, or the use of more aggressive pharmaceutical price negotiating techniques by Medicare.

Call it whatever you like

These and other ideas are longstanding wish-list items that have been floating around in various corners of the Democratic Party. You could, in theory, bundle them up with something technocratically sound but unpopular like a stronger individual mandate, or you could throw in something business-friendly like relaxing the employer mandate. Replacing the “Cadillac Tax” on expensive health insurance premiums (a policy labor unions hate) with a 28 percent cap on the deductibility of health insurance would probably also make sense here.

But the great thing about all these ideas is that they’re consistent with both longstanding Democratic ideas and popular things Donald Trump said on the campaign trail.

Democrats can characterize them as Affordable Care Act “fixes” or “tweaks” or “improvements” if they want to. Or they can call it an “alternative” or “replacement” to the ACA if that sounds better. Heck, they can even call it “Trumpcare.”

The important thing is that devising a plan would make two points. On the one hand, it would show that Democrats are not indifferent to the fact that the ACA has not been roses and unicorns for everyone. On the other hand, it would show that Obama’s challenge to the GOP to show him something demonstrably better for patients is honestly not that hard a standard to meet. [emphasis mine]

Yep.  It’s not hard at all policy-wise to accomplish what Trump wants.  The problem is a political one– Republicans are ideologically (one could say, theologically) opposed to greater government involvement (e.g., public option), despite the fact that this would help lead to health care for more people at a lower price.

Seriously, it’s really not that hard to dramatically Obamacare and save money doing it.  When it comes to the health care, it is simply the theology of the Republican party that prevents us from having nice things.

Quick hits (part II)

1) Would really like to see some rigorous studies of microdosing with LSD.  I think there is some real potential there.  Alas, all we are left with is lots of anecdotes– like Ayelet Waldman’s— thanks to good old schedule I.

2) Not all that surprisingly, if you want your kids to have safer sexual practices you should, you know, talk to them about sex.  Also, boys get left out of this a lot.

3) Farhad Manjoo on how Netflix is deepening our cultural divide:

Yet for a brief while, from the 1950s to the late 1980s, broadcast television served cultural, social and political roles far greater than the banality of its content would suggest. Because it featured little choice, TV offered something else: the raw material for a shared culture. Television was the thing just about everyone else was watching at the same time as you. In its enforced similitude, it became a kind of social glue, stitching together a new national identity across a vast, growing and otherwise diverse nation.

“What we gained was a shared identity and shared experience,” Mr. Strate said. “The famous example was Kennedy’s funeral, where the nation mourned together in a way that had never happened before. But it was also our experience watching ‘I Love Lucy’ and ‘All in the Family’ that created a shared set of references that everyone knew.”

As the broadcast era changed into one of cable and then streaming, TV was transformed from a wasteland into a bubbling sea of creativity. But it has become a sea in which everyone swims in smaller schools.

4) Republican legislators in two states looking to abolish tenure at public universities.  Presumably, only a matter of time before NC legislators get this idea.

5) I saw “Silence” with David yesterday and we both really, really liked it.  Powerful and thought-provoking.  It certainly took it’s time, but I was never bored.

6) The real problem for teacher in NC says an NC teacher?  Not enough time.  I will totally buy that.

7) It’s Girl Scout Cookie time.  Loved this feature in the LA Times that lays out the differences in the cookies between the two bakeries.  I grew up loving “Samoas” and my wife grew up loving “Carmel Delites.”  This graphic shows that, clearly, Samoas are superior.

8) On Ivanka Trump’s fake feminism.

9) Loved this James Kwak piece on “economism” as applied to the minimum wage:

The argument against increasing the minimum wage often relies on what I call “economism”—the misleading application of basic lessons from Economics 101 to real-world problems, creating the illusion of consensus and reducing a complex topic to a simple, open-and-shut case. According to economism, a pair of supply and demand curves proves that a minimum wage increases unemployment and hurts exactly the low-wage workers it is supposed to help…

The real impact of the minimum wage, however, is much less clear than these talking points might indicate. Looking at historical experience, there is no obvious relationship between the minimum wage and unemployment: adjusted for inflation, the federal minimum was highest from 1967 through 1969, when the unemployment rate was below 4 percent—a historically low level. When economists try to tackle this question, they come up with all sorts of results. In 1994, David Card and Alan Krueger evaluated an increase in New Jersey’s minimum wage by comparing fast-food restaurants on both sides of the New Jersey-Pennsylvania border. They concluded, “Contrary to the central prediction of the textbook model … we find no evidence that the rise in New Jersey’s minimum wage reduced employment at fast-food restaurants in the state.”

10) Seven hard questions about health care reform that Democrats need to hold Republicans feet to the fire on.

11) The areas where both experts and the public agrees on effective gun control.  Hey, maybe give these a try!  Oh, right, Republican politicians are not in these charts.

12) Neither GRE’s nor undergraduate GPA appear to be particularly good measures of graduate school success.  Well, that makes things difficult.

13) The latest PS research on Voter ID and vote suppression.  This is important:

The proliferation of increasingly strict voter identification laws around the country has raised concerns about voter suppression. Although there are many reasons to suspect that these laws could harm groups like racial minorities and the poor, existing studies have been limited, with most occurring before states enacted strict identification requirements, and they have uncovered few effects. By using validated voting data from the Cooperative Congressional Election Study for several recent elections, we are able to offer a more definitive test. The analysis shows that strict identification laws have a differentially negative impact on the turnout of racial and ethnic minorities in primaries and general elections. We also find that voter ID laws skew democracy toward those on the political right.

14) Saw some pretty strong liberal pushback against this NYT piece, but I think it is worth having a reasonable discussion over whether we should be subsidizing the purchasing of sugar soda through food stamps.  Maybe that opens a Pandora’s box, but it seems that we could probably all agree this is not something the government should be subsidizing.

15) Quirks and Quarks just did a whole show on mindfulness meditation.  This segment was the best explanation I’ve yet heard.

 

16) Good stuff from Roger Cohen:

Trump’s psyche is no great riddle. He’s a study in neediness. Adulation is what he craves; admonishment he cannot abide. Trafficking in untruths and conspiracies, he calls the press that he secretly venerates dishonest for pointing this out. That’s called transference. Soon he will have at his disposal far more potent weapons than Twitter to assuage his irascibility and channel his cruelty. It is doubtful that he will resist them over time. There is rational cause for serious alarm. If the world was anchored by America, it is about to be unmoored.

17) Gender bias in health care is a real problem.  How checklists can fix it.

18) Evan Osnos on the Senate confirmation process:

Trump is making an astonishing bet that he will be the first President in a quarter century to manage not to have a single nominee disqualified. And he is betting that the American people, having just elected the first modern President to refuse to release his tax returns, are, in effect, done with ethics. He is betting that, like his oft-cited prediction that he could shoot someone and not lose votes, virtually nothing that could come out after a nominee is confirmed will undermine his Presidency. He is betting, in effect, that we’re too dumb or too demoralized to care.

19) These fake books are so hilarious.

20) I may have posted this before, but if so, I just re-came across it.  I’ve been saying for years that free, widespread, encouraged IUD use is the best anti-poverty program we could have.  Jordan Weissman explains.

 

 

Quick hits (part I)

1) Yglesias on how Trump’s domestic policy agenda is really GWB part II.

Bush rode into office on the strength of white working-class voters who were drawn to his heartland cultural politics, alienated by Al Gore’s aloof demeanor, and appeased by Bush’s repudiation of the hard-right orthodoxy of the congressional GOP of the era. Bush scolded congressional Republicans for seeking to “balance the budget on the backs of the poor” and promised to deliver a much-needed prescription drug benefit to America’s senior citizens.

“George Bush is a different kind of right-winger,” wrote the Economist’s US politics columnin April 2001, “a card-carrying conservative who nevertheless believes in active government.”

Fred Barnes of the Wall Street Journal and the Weekly Standard called him a “big government conservative.”

None of this entailed a retreat from the Republican Party’s basic commitment to an agenda of tax cuts for high-income households and favorable regulatory treatment of businesses. It was, instead, a political strategy to make plutocracy workable. And while Bush-era deficits probably contributed to some long-term problems, the interest rate environment of the time was certainly conducive to “irresponsible” budgeting.

And, indeed, it’s very difficult to imagine Bush securing reelection in 2004 if his trillion-dollar tax cut had been paid for with cutbacks to public services. In reality, however, Bush expanded public services by lavishing new subsidies on American agriculture, introducing new health benefits on American seniors, and increasing federal K-12 education spending in exchange for the accountability reforms of the No Child Left Behind law.

When, eventually, Bush’s administration collapsed into ignominy, conservatives quickly pinpointed these big-spending ways as the reason. Even Bush’s brother Jeb found himself saying that “in Washington during my brother’s time, Republicans spent too much money.”

But by the time Jeb was out on the campaign trail distancing himself from his brother’s big-spending ways, Trump was kicking his butt precisely by distancing himself from the tight-fisted fiscal policies of Paul Ryan and Mitch McConnell.

2) Trump takes credit for a $1 billion investment in the US.  Drum points out that this happens about once per day, on average.

3) Wired on Apple’s need to move past the Iphone, on its 10-year anniversary.

4) And David Pogue’s take on the original Iphone from 10-years ago.  Nice reminder of how revolutionary it was.

5) Jeff Sessions should not be our next Attorney General.

6) Neurotracker has convinced professional teams and athletes that it can improve their performance by improving the mental tracking so key in many sports.  Alas, there’s no real evidence it actually does.  It’s honestly a pretty easy experiment to do (randomly assign a college or HS football, soccer, etc. team with experimental and control for a couple weeks, then test), so the fact that there’s not any such evidence makes me very skeptical.  I find the following critique compelling:

Williams, at the University of Utah, challenged the notion that tracking bouncing objects in a simulation could train or quantify anything other than a person’s ability to track bouncing objects in a simulation.

“I’ve never seen a soccer player chasing multicolor balloons around on the field,” Williams said. “It’s just not what soccer players do.”

What soccer players do, he said, is read patterns of play, anticipate what might happen next based on movements of teammates and opponents, and identify familiar sequences as they unfold. This “inside” knowledge, built up over time, promotes the effectiveness and efficiency that Ericsson argues are the hallmarks of expertise.

7) My 10-year old Evan received a mini-drone for Christmas.  A friend said, “so what do you do with it?”  My response, “crash it.”  Managed to actually get it down from 30 feet up in a tree where I stranded it within the first 5 minutes.  Loved this NYT article on Christmas drone horror stories.  We still have our and it still works and we’ve only broken to propellers.  We’ll try again when all our snow and ice melts.

8) This essay by Karl Marlantes on how Vietnam permanently disrupted Americans’ faith in their government is a must read.  (Also makes me think I need to move his novel, Matterhorn, further up my queue).

In the early spring of 1967, I was in the middle of a heated 2 a.m. hallway discussion with fellow students at Yale about the Vietnam War. I was from a small town in Oregon, and I had already joined the Marine Corps Reserve. My friends were mostly from East Coast prep schools. One said that Lyndon B. Johnson was lying to us about the war. I blurted out, “But … but an American president wouldn’t lie to Americans!” They all burst out laughing.

When I told that story to my children, they all burst out laughing, too. Of course presidents lie. All politicians lie. God, Dad, what planet are you from?

Before the Vietnam War, most Americans were like me. After the Vietnam War, most Americans are like my children.

America didn’t just lose the war, and the lives of 58,000 young men and women; Vietnam changed us as a country. In many ways, for the worse: It made us cynical and distrustful of our institutions, especially of government. For many people, it eroded the notion, once nearly universal, that part of being an American was serving your country.

9) Gotta love that the guns rights folks (and DJT Jr) are arguing that we need to make it way easier to buy silencers/suppressors, through legislation titled The Hearing Protection Act.

10) Love that a Dairy Queen owner who unleashed racist rants on his customers had his franchise pulled from him by DQ corporate.  That’s the power of social media for good.

11) The insanity of trying to get even a low-level Senate confirmation from today’s dysfunctional Congress.  Though, that will change.

12) Greg Sargent on Trump’s (lying, of course) response to Meryl Streep:

It’s often argued that we should perhaps give less attention to Trump’s tweets. But Monday’s barrage gets at something important. Yes, all politicians lie. But with only days to go until Trump assumes vast power, Monday’s tweetstorm is a reminder that we may be witnessing something new and different in the nature and degree of the dishonesty at issue. Here again we’re seeing Trump’s willingness to keep piling the lies on top of one another long after the original foundational lies have been widely debunked, and to keep on attacking the press for not playing along with his version of reality, as if the very possibility of shared reality can be stamped out by Trumpian edict, or Trumpian Tweedict.

13) Among the dumbest things we do in American democracy: abysmally poor compensation for state legislators.  Because, you know, it’s not like what state governments do is important or anything.  NPR:

While a few big states have full-time legislatures with higher pay (California pays lawmakers $100,113 a year and Pennsylvania pays $85,339) but in most states, legislators are paid like it’s a part-time job.

According to data compiled by the National Conference of State Legislatures, 30 states pay $30,000 a year or less to legislators. New Mexico doesn’t pay lawmakers at all, while those in New Hampshire make just $200 per two-year term…

Median household income in the United States was $55,775 in 2015, according to the Census Bureau.

“Not paying legislators is like a very penny-wise, pound foolish thing,” given the size of state budgets and complexity of issues that legislatures tackle every year, said Stanford University political scientist Neil Malhotra.

That low level of pay also keeps many people from entering politics, said Malhotra. “There’s very, very few working class people in legislatures. This might have something to do with why a lot of legislation does not seem very friendly towards working class people.”

14) I don’t doubt that there really is something to “attachment theory” that proper bonding in very-early childhood can be key for personality throughout life, but this article is absolutely preposterous in not addressing the role of genetics in this issue.  Any parent of more than one child can sure as hell tell you that.

15) How video game designers need to engineer in just the right amount of luck.

16) The difficulty in enforcing ethics laws under Trump.

17) Yglesias reminds of what we do know about Trump and Russia:

18) The Amherst College new mascot– Hamsters.  Kind of love it.  Kind of think it’s silly to change a mascot based on the now-odious, but mainstream enough in the 18th century views, of Lord Amherst.

19) Interesting idea from Democratic Senator Sheldon Whitehouse— many Republican politicians actually want to fight climate change but the fossil fuel industry they are beholden to will not let them.  I’m not convinced.  If true, just more profiles in cowardice.

20) Even if you have good health insurance through your employer, an ACA repeal can really hurt you, too.

21) Hooray for San Diego for not being a hostage to the NFL and refusing to spend hundreds of millions of public dollars to further enrich a billionaire.  And, on the not-so-great economics of having an NFL team in your city.

22) Some interesting research suggests conservative politicians in several countries are more attractive than liberal politicians.

23) This long, thoughtful, post from an Ohio teacher on our way over-reliance on standardized testing is really, really good:

The most critical solution to this is to untie student, teacher, and school accountability measures from testing outcomes, or to combine these scores with a variety of other measures of success. In addition, we need to dramatically reduce the time spent on testing by requiring tests in fewer grades, or not administering tests every year. No high-performing nation in the world tests all students annually…

We are not in an education crisis. We are in a crisis of poverty that is being exacerbated by the school accountability movement and the testing industry. At best, this movement has been misguided. At worst, it is an intentional set up to bring about the demise of the public education system – mandatory testing designed to produce poor results which leads to greater investment made in test preparation programs provided by the same companies who produce the tests, coupled with a related push for privatization of the educational system. All touted as a means to save us from this false crisis.

24) Best explanation I’ve yet read for why recent rules changes have led to college football being so high scoring (it’s all about the blocking on the run-pass option).

25) Pippa Norris responds to the many issues raised on the whole “is North Carolina a democracy” flap.

 

 

Obamacare repeal = huge tax cut for America’s wealthiest

Since one of my regular commenters who is normally pretty up on things missed this point, I figured it was worth emphasizing.  Not to mention, I’ve seen a few good posts elsewhere on the matter.  Jordan Weissman’s take captures the dynamic nicely:

Obamacare is a complicated law with lots of interlocking parts that make it tricky to understand. But one of the core, very simple things it did was raise taxes on the wealthy in order to fund subsidized health care for more Americans. Couples earning more than $250,000 saw a 0.9 percent increase in their top Medicare tax rate, as well as a new, 3.8 percent Mediare surtax on investment income.

If Republicans have their way and successfully repeal the Affordable Care Act, those two taxes will be toast—which will mean a substantial break for some of the country’s wealthiest families. The liberal Center on Budget and Policy Priorities estimates that millionaires would see 80 percent of the benefits from those tax reductions. Based on the most recent IRS data, the think tank roughly projects that the 400 highest income households—which earned an average of more than $300 million each in 2014—would see a $2.8 billion annual tax cut, worth about $7 million on average per filer. To put that in some perspective, that’s a smidge more than Obamacare is set to spend on insurance premium tax credits in the 20 smallest states and the District of Columbia…

Republicans cutting benefits for the working class and poor in order to fund tax cuts for the wealthy is a dog bites man story if there ever was one. But by repealing Obamacare’s sources of funding, the GOP is putting itself in a little bit of a bind. After all, any viable Republican replacement plan—should one actually ever come into existence, as promised—is going to presumably require some funding. Once Congress has dumped the Affordable Care Act’s taxes into the dustbin of fiscal history, however, a lot of Republicans may be nervous about raising taxes to fund their own proposal. What happens at that point? Your guess is good as mine.

Weissman is right, this is dog bites man.  But this is a really big dog with strong set of teeth.  And, it’s one of the reasons Republican politicians hate Obamacare– a core feature is a clear redistribution of wealth from America’s wealthiest to the poor and middle class.

The reason Obamacare has not been repealed yet

Because it is very, very hard, both policy-wise and the politics (i.e., taking health care away from 20 million people is never going to look good).

Ezra Klein on the policy and political trade-offs:

The trade-off here is sharp. One way Republicans could achieve the same coverage levels at a lower cost is to allow insurers to offer stingier, sparer products. But those products would mean more people lose access to doctors they were happy with, and more people end up in plans whose deductibles they can’t actually afford.

That’s bad politics. Good politics is doing what Trump did and promising that voters “can have their doctors, they can have plans, they can have everything.” The problem is that’s a promise that zero of the GOP replacement plans keep.

The same is true on coverage. Republicans could decide that their Obamacare replacement will be cheaper because it will cover fewer people. And, to be fair, there are a number of Republican replacement ideas floating around, and all of them would leave millions uninsured compared with Obamacare.

But taking away insurance people already have is — as the Obama administration already learned — wildly, wildly unpopular. And Republicans know that too. On Monday, Kellyanne Conway, one of Trump’s top advisers, said, “We don’t want anyone who currently has insurance not to have insurance” — a principle that disqualifies every Republican repeal plan, including Trump’s own.

The same dynamic reasserts itself on deficits, spending, and taxes. Republicans often criticize Obamacare for increasing the deficit — which it actually doesn’t do. More fairly, they criticize it for raising taxes and cutting Medicare spending, both of which it really does do. Voters also dislike Obamacare’s tax hikes and spending cuts. But to the extent that you repeal Obamacare’s pay-fors, you increase the debt…

But Obamacare’s goals were, at least, popular. It’s not clear that the Republican Party’s goals actually are popular. Do people abstractly support fewer Americans having health insurance? Or more high-deductible plans? Or changes to the tax code that would begin to weaken the link between employers and health coverage? This is, in reality, why Republicans are so cagey about their replacement plans: They’re not sure the country will like what they offer.

As long as you’re working with private insurance, you run into what I call the iron law of private sector health reform (catchy, right?): You can have any two of good insurance, low premiums and deductibles, or low taxes. But you can’t have all three.

Chait on the difficulty of repeal and delay:

From the standpoint of the most ideologically committed elements of the conservative base, destroying Obamacare was always the most salient pledge. Republican rhetoric treated the law as an existential threat to American freedom — the worst thing since slavery, as incoming Trump cabinet member Ben Carson put it. But from the standpoint of the electorate as a whole, the pledge to replace it with “something terrific,” as Trump put it, mattered just as much. A large number of Trump voters who get coverage through Obamacare “simply felt Trump couldn’t repeal a law that had done so much good for them,” reports Sarah Kliff, who spoke with many of them.

But any plan to replace Obamacare with something “terrific,” or even something almost as good as Obamacare, will violate conservative dogma. There’s no way around this. Despite the apparent complexity of the issue, it’s a very simple problem of resource allocation. In a free-market system, tens of millions of Americans will not be able to afford medical care because the cost of their treatment exceeds their income, either because they’re too poor, or because they’re too sick. A Kaiser Family Foundation analysis finds that 52 million Americans under the age of 65 have preexisting conditions that would make it impossible for them to purchase health insurance in the individual market that existed before Obamacare. An insurance-industry study from 2008 found that 13 percent of people who applied for coverage in the individual market were rejected — a figure that doesn’t even count the 34 percent of people who had to buy policies that excluded coverage of treatments for their preexisting conditions, let alone those who didn’t even bother applying because they knew they couldn’t afford it.

Covering people who can’t afford to pay for their own medical care means making other people pay for it. You can do that through direct tax-and-spend transfers, or through indirect regulatory methods (like making insurance companies overcharge healthy people and undercharge sick ones). Republicans oppose these methods because they oppose redistribution in general. And yet politics requires them to promise a plan that does not deprive Americans of access to treatment. This is the reason none of their plans has advanced beyond the white-paper concept phase —either they contain too much redistribution to be acceptable to the GOP, or too little coverage to be acceptable to the public, or both…

Repeal-and-delay is the ultimate backhand acknowledgement that the party has no answers. Their wan hope is that by repealing the law, they can satisfy the blood lust of conservative activists. The repeal won’t take place for years. Then they can hide under some coats and hope it all works out. [emphasis mine]

But even this step has proven extremely tricky. If Republicans repeal Obamacare without creating a replacement, insurers will have little reason to stay in the marketplace. They’ll start canceling plans immediately, and the news will be filled with stories of Americans being thrown off their medication and, in some very real cases, dying. Repeal-and-delay will actually require taking additional action to prevent a meltdown.

And Sarah Kliff thinks this is all so difficult that there’s a real chance a repeal won’t even happen:

The Republican Party is fracturing around Obamacare in ways we haven’t seen before. This is happening for a simple reason: It’s really, really hard to end health insurance benefits for 20 million Americans, especially when you don’t have a plan for what comes next. I still think repeal is the most likely outcome of this debate — it just doesn’t seen nearly as certain possibility as it did a month ago.

I’ve spent seven years covering the Affordable Care Act, and right now I honestly don’t know what will happen next. It is reminiscent of the early days of Democrats’ health care debate, when we legitimately did not know if the party would succeed in passing the largest expansion of coverage in decades.

We don’t know, for example, how seriously Republican senators oppose repeal and delay — whether these are some initial protests that will die down, or if they are serious about voting against the approach. We don’t know if Obamacare repeal will face protest from the right-wing House Freedom Caucus, which doesn’t like the idea of putting off Obamacare repeal at all.

Now, surely Republicans will come up with something they label “repeal” but it’s really not too much of a stretch to imagine something like what Indiana did with replacing “Common Core” with a new set of standards that are still basically Common Core.  That said, I wouldn’t put it past them to just take health insurance away from 20 million Americans.  One this is certain– the current situation is incredibly uncertain and could go in any number of a possible ways.

P.S.  After I queued the post last night, a new post from Chait concludes:

That’s why repeal and delay was the best chance to destroy Obamacare. The gamble was that, by blowing up the health care system on a fuse, Republicans could pressure Senate Democrats into going along with a Republican friendly replacement. The details might be unpopular, but coerced Democratic support might give it cover. But this plan only works if 50 Senate Republicans are willing to gamble that they can hold the one-seventh of the economy consumed by health care as a hostage and force a bunch of Democrats to go along. If that gamble fails, the ruin could easily trigger a backlash against the majority party. Apparently not enough Senate Republicans are willing to roll the dice. If this holds, Obamacare, or something substantially similar, is probably going to survive.

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