Last Friday, shortly after the failure of the GOP health care bill, President Trump spoke from the Oval Office to reassure worried Americans that, while their healthcare system would soon fail, he and his friends would be just fine. "I've been saying for the last year and a half that the best thing we can do politically speaking is let Obamacare explode," said the populist leader about a healthcare program that helps the voters who elected him, one that even deep-red Kansas has begun to embrace.But while Trump seems to advocate for a hands-off approach to Obamacare while he attends to other matters—like building a structurally impossible wall—others like Paul Ryan aren't ready to give up on ending one of the fastest expansions of health coverage in US history without a fight."What will Trump do next?" is something we have to constantly ask ourselves now, apparently.
Here are four possible ways forward for healthcare now that the American Health Care Act is off the table (or not?) but the GOP is still very much in charge.Possibility No. 1: Obamacare stays as-is, and doesn't collapse
No, Obamacare is not exploding or in a death spiral or in whatever other cool-sounding synonym the GOP has for what would amount to the pain and ruin of millions. In fact, Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities, makes the opposite case: Obamacare is doing exactly the opposite of what we'd expect if the market were collapsing. It is improving."When a market is in collapse, it is declining in enrollment, not increasing," Lueck says. But using "arithmetic," we are able to see that coverage has increased in the marketplace every year since the ACA took full effect in 2014.In a collapse or death spiral, there's a feedback loop: Healthy people don't buy coverage, which forces the prices up because insurers can't offset the costs of sicker people, so more healthy people don't enroll, which forces the prices up even higher, which…you get the point."That isn't at all what's happening here," Lueck says. Not only do we have increasing enrollment, but people are insulated from premium increases because their subsidies rise with those increases. While the GOP may welcome the collapse of the healthcare system, Obamacare was designed against it."If we were in a completely clear environment where no one was trying to kill the law, we would have a really good year going into 2018," Lueck says.How likely is this? Not very.Possibility No. 2: Trump and the GOP intentionally dismantle the system
It isn't often that we call people up and ask them how they'd destroy the healthcare system, since that sort of thing sounds like something a really patient supervillain would do, but there are clear ways the Trump administration and the GOP might nudge Obamacare toward collapse.One obvious way to blow up the healthcare system: The Trump administration ends payments on cost-sharing subsidies, which the government gives to insurers to help offset the cost of covering people with low incomes (up to $50,040 for a family of three). More than half of the people who buy insurance through the marketplace—5.9 million people—benefit from these subsidies, and it makes a big difference when working class families need to pay up-front (deductible) costs at the doctor.In what is sure to one day become a treasured courtroom drama, in 2014 House Republicans stood up for what they believed in and sued the Obama administration to end this practice of helping people when they're sick. The Trump administration doesn't need to leave the decision in the hands of judges: They could choose not to defend the lawsuit or stop paying the bill. "If they stop making those payments, that's a surefire way of making the market explode," says Cynthia Cox, associate director for the program for the study of health reform and private insurance at the Kaiser Family Foundation.The other obvious way to destroy the ACA is to weaken the individual mandate. There are two ways that this could be done, one through the IRS and one through the Department of Health and Human Services. Since Trump's inauguration day executive order told federal agencies they could gut Obamacare to "the maximum extent permitted by law," the IRS will now accept tax returns that don't say whether you have health insurance. HHS could also issue very broad personal hardship exemptions, which "would have the same effect as repealing the mandate," Cox explains.In places where there are serious coverage issues and a county might have zero insurers, Trump can respond to the 3 AM phone call question by just not answering the phone. When Pinal County in Arizona faced the very prospect of no insurers last year, the Obama administration and the state worked together with insurers to get coverage. Trump could just let the phone ring.How likely is this? It's already happening.Possibility No. 3: They passively let it crumble
There are also subtle ways that the Trump administration could blow up Obamacare, and some of them have already begun. The Center for Budget and Policy Priorities has created "Sabotage Watch," which is "tracking efforts to undermine the ACA," often in ways that aren't super obvious and given non-threatening names like "market stabilization." For example, shortly after Valentine's Day, they proposed cutting the enrollment period in half, from 90 to a mere 45 days, and requiring more documentation and paperwork in order to access special enrollment (say, if you lose your job or have a baby).And, as we have covered previously, they could dramatically change Obamacare without a single vote in Congress: Tom Price and HHS can take away health benefits that they don't like, such as access to free birth control, simply by redefining what counts as a "preventive health service."Even if Trump and the GOP don't actively undermine Obamacare, the chaos itself may be enough for them to see it burn. "This uncertainty is poisonous to the insurance market," Lueck says. "The industry hates uncertainty. They're in the business of financing risk and they can't do that as well if they don't know what the rules are going to be."How likely is this? It, too, is already happening.Possibility No 4. Someone comes up with a better idea
Even if the American Health Care Act, or its most recent version, isn't the future of healthcare in America, don't count the GOP out: They are hardly out of bad ideas.A few weeks ago, Rep. Pete Sessions (R-TX) brought to the House floor a healthcare bill called "World's Greatest Healthcare Plan of 2017." It would make sure health insurance is no longer burdened to provide "preventive care at no cost or include the essential health benefits." Imagine how cheap healthcare will be without prescription drugs or emergency care!And earlier, Tom Price introduced the "Empowering Patients First Act" (later re-introduced by John McCain), which would in some cases remove protections for people with pre-existing conditions, a feature of Obamacare that nearly 90 percent of the country supports.But if Trump and the GOP are serious about a health care reform plan, they'll need to solve a paradox: How do you appease the moderates in your party who thought the consequences of the repeal went too far while also appeasing the ultra-conservative in your party who didn't think they went far enough?Some, on the left, believe we shouldn't let the crisis of the GOP go to waste: Now may be the perfect time to introduce a single-payer health option, which under Senator Bernie Sanders' plan would consist of Medicare for all and guaranteed universal health coverage.Experts point out, however, that historically we have not gotten such a revolutionary change in the role of government in healthcare without a major crisis. "The ways in which we get large expansions of the role of government is not just from health policy," Cox says, "but it's also from extenuating circumstances like wars or recessions." Huh, in that case, there's a chance!
Advertisement
Here are four possible ways forward for healthcare now that the American Health Care Act is off the table (or not?) but the GOP is still very much in charge.Possibility No. 1: Obamacare stays as-is, and doesn't collapse
No, Obamacare is not exploding or in a death spiral or in whatever other cool-sounding synonym the GOP has for what would amount to the pain and ruin of millions. In fact, Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities, makes the opposite case: Obamacare is doing exactly the opposite of what we'd expect if the market were collapsing. It is improving."When a market is in collapse, it is declining in enrollment, not increasing," Lueck says. But using "arithmetic," we are able to see that coverage has increased in the marketplace every year since the ACA took full effect in 2014.In a collapse or death spiral, there's a feedback loop: Healthy people don't buy coverage, which forces the prices up because insurers can't offset the costs of sicker people, so more healthy people don't enroll, which forces the prices up even higher, which…you get the point.
Advertisement
It isn't often that we call people up and ask them how they'd destroy the healthcare system, since that sort of thing sounds like something a really patient supervillain would do, but there are clear ways the Trump administration and the GOP might nudge Obamacare toward collapse.One obvious way to blow up the healthcare system: The Trump administration ends payments on cost-sharing subsidies, which the government gives to insurers to help offset the cost of covering people with low incomes (up to $50,040 for a family of three). More than half of the people who buy insurance through the marketplace—5.9 million people—benefit from these subsidies, and it makes a big difference when working class families need to pay up-front (deductible) costs at the doctor.In what is sure to one day become a treasured courtroom drama, in 2014 House Republicans stood up for what they believed in and sued the Obama administration to end this practice of helping people when they're sick. The Trump administration doesn't need to leave the decision in the hands of judges: They could choose not to defend the lawsuit or stop paying the bill. "If they stop making those payments, that's a surefire way of making the market explode," says Cynthia Cox, associate director for the program for the study of health reform and private insurance at the Kaiser Family Foundation.
Advertisement
There are also subtle ways that the Trump administration could blow up Obamacare, and some of them have already begun. The Center for Budget and Policy Priorities has created "Sabotage Watch," which is "tracking efforts to undermine the ACA," often in ways that aren't super obvious and given non-threatening names like "market stabilization." For example, shortly after Valentine's Day, they proposed cutting the enrollment period in half, from 90 to a mere 45 days, and requiring more documentation and paperwork in order to access special enrollment (say, if you lose your job or have a baby).
Advertisement
Even if the American Health Care Act, or its most recent version, isn't the future of healthcare in America, don't count the GOP out: They are hardly out of bad ideas.A few weeks ago, Rep. Pete Sessions (R-TX) brought to the House floor a healthcare bill called "World's Greatest Healthcare Plan of 2017." It would make sure health insurance is no longer burdened to provide "preventive care at no cost or include the essential health benefits." Imagine how cheap healthcare will be without prescription drugs or emergency care!And earlier, Tom Price introduced the "Empowering Patients First Act" (later re-introduced by John McCain), which would in some cases remove protections for people with pre-existing conditions, a feature of Obamacare that nearly 90 percent of the country supports.But if Trump and the GOP are serious about a health care reform plan, they'll need to solve a paradox: How do you appease the moderates in your party who thought the consequences of the repeal went too far while also appeasing the ultra-conservative in your party who didn't think they went far enough?Some, on the left, believe we shouldn't let the crisis of the GOP go to waste: Now may be the perfect time to introduce a single-payer health option, which under Senator Bernie Sanders' plan would consist of Medicare for all and guaranteed universal health coverage.Experts point out, however, that historically we have not gotten such a revolutionary change in the role of government in healthcare without a major crisis. "The ways in which we get large expansions of the role of government is not just from health policy," Cox says, "but it's also from extenuating circumstances like wars or recessions." Huh, in that case, there's a chance!