The ACA Will Survive, And Be the Basis For a Better Statute

The No Billionaire Left Behind Act will apparently repeal the tax penalty for not carrying health insurance in the Affordable Care Act. This is, to be clear, like pretty much everything in the Republican policy agenda bad policy. It will mean millions of fewer people with insurance and insurance being more expensive for many of those who purchase it on the exchanges. That’s not good.

But is this the end of the ACA? Of course not:

I surveyed four health care lobbyists well attuned to congressional Republicans after Jones’s win, and three of them flatly said that Obamacare repeal was dead. The other offered only that they might indeed try again, giving the GOP’s existential opposition to the health care law.

But ironically, the sweeping tax bill Republicans are poised to pass, which also ends Obamacare’s individual mandate, could actually make it harder to repeal the rest of the law. Republicans will have nixed the least popular part of the ACA — the part that has been the foundation of their ideological opposition.

The Republicans didn’t have 50 votes to repeal the popular parts of the ACA this year and they’re not going to get them during an election year.

As Scott says, repealing the mandate will weaken the exchanges, but since they’ve relied more on the subsidies than the tax penalty it won’t destroy them, especially in states committed to making them work:

The law’s individual marketplaces aren’t going to work as well without it. But they probably aren’t going to collapse either. Most policy experts already think two things:

The mandate is too weak to compel more people to buy insurance. For many people who might be on the fence, it is still cheaper to pay the penalty than to purchase health coverage.

Most people who don’t receive subsidies are being priced out of the market. The people who remain in the market receive subsidies that protect them from rising premiums without the mandate.

The Obamacare markets without the mandate are likely to shrink to the people who receive generous subsidies and sick people who really need insurance. That is not an ideal market. But it still means millions of people will be able to afford comprehensive insurance under the law.

Even more importantly, the best part of the ACA remains in place, albeit as ineptly re-written by John Roberts:

But then you have the rest of the law still in place. Obamacare expanded Medicaid eligibility to cover everybody with an income up to 133 percent of the poverty level (about $16,000 for an individual). It has covered more than 15 million people, according to the Kaiser Family Foundation, making up more than half of the coverage gains under the law.

So the Obamacare that will remain is one that still covers more than 20 million of the poorest Americans. Other Republican-led states that have so far rejected the Medicaid expansion could revisit their decision the longer the law stays on the books.

Protecting the Medicaid expansion was by far the most important thing in this year’s health care struggle, and it appears to have survived. The next Democratic government will focus on the expansion of Medicaid and/or Medicare, and as whatever markets have to fill in the remaining gaps are more likely to be strengthened with the carrot of subsidies rather than the stick of tax penalties. All of these are good things. The repeal of the mandate is bad, but it doesn’t make the victories of earlier this summer for naught.