Repeal and Replace. Repeal and Replace. Repeal …

Repeal and replace.  Simple enough on the campaign trail.  We heard this promise in 2010, when voters gave the House to Republicans.  We heard it again in 2012, when voters gave them the Senate.  Despite controlling Congress, Obamacare remained the law of the land.  Candidate Donald Trump, along with most Republican members of Congress, promised repeal and replace last year.

Republicans now have their largest electoral majority in nearly a century, and repeal and replace is spinning its wheels, like an old Pontiac stuck in the snow.

Some think a grand bill is still possible, particularly Senate majority leader Mitch McConnell.  Others are skeptical.  Senators Rand Paul and Mike Lee favor a two-pronged approach: repeal first then repeal later.  Herein lies the problem.  Republicans can’t agree on anything.

Democrats had no such problem in 2010 when they passed Obamacare.  The Bernie coalition didn’t get a single-payer plan as they wanted.  Some wanted higher Medicaid reimbursement for their states, as in the “Cornhusker Kickback.”  But they came together and passed Obamacare, each Democrat getting most but not all of what he wanted.

There’s nothing similar on the Republican side, which is why repeal and replace, as a single bill, is spinning its wheels.  Whether in the House or the Senate, any bill provision that pleases conservatives will lose moderate votes, and vice versa.  So no grand unifying bill will emerge as there won’t be enough Republican support for passage.

It’s all much like a carnivore and a vegetarian trying to plan a meal.  Add meat to the dish, pleasing the meat-eater, and the vegetarian won’t touch it.  Make it veggies and tofu, and the meat-eater will grab a burger instead.

This is why separating the two bills is the only reasonable option at this point.  Two casseroles, one with meat and one without.  Something for everyone…but separate.

There are enough votes for a repeal.  The House has voted on and passed such a measure several times.  If the Senate cannot currently agree on a replacement plan, just repeal now and replace later.

What could go wrong with that?  Plenty.  Congress is famous for making promises it doesn’t keep.  Budgets are a great example.  How many times did a Republican Congress pass a bloated budget or continuing resolution, or raise the debt limit, only to tell everyone that “next time,” they will put their foot down and show fiscal restraint?  It’s like Lucy pulling the football away from Charlie Brown each time despite promises to the contrary.

If they vote for repeal only, it won’t go into effect immediately.  There will be a phase-out period of several years.  Individuals, business, and particularly insurance companies need time to adjust.  Insurance is based on actuarial risk, predicting the future.  Businesses and individuals financially plan based on the rules of the game going forward.  An individual might delay elective surgery or have it sooner based on future insurance coverage.  It’s the same for businesses investing in additional employees or capital equipment based on potential future employee insurance expenses.

A replacement, while not necessary immediately, needs to be forthcoming in order to allay the uncertainty that is poison to businesses, the insurance industry, and the financial markets.  And the timing of the repeal process provides a deadline, one of life’s great motivators.

Once repealed, the clock begins ticking for replacement.  But Congress will at least have a clean slate.  Rather than applying Band-Aids and duct tape to the failing Obamacare plan, they can create a new plan from the ground up.  They can even bring along some Democrat involvement, at least among those few willing to work for the benefit of the country rather than sucking their thumbs, criticizing and complaining about Trump and Republicans.

That’s fertile ground for new health care delivery plans, whether a two-tiered approach or more of a free-market plan with expanded health savings accounts and vouchers for those in financial need.  It is far easier to create a new plan without trying to fit a replacement into the framework of a failing existing plan.

Like it or not, the health care ball is now in the Republican court.  They made promises to American voters and were given congressional majorities to stop the Democrat agenda and fix longstanding problems, whether immigration, taxes, regulations, trade, or health care.  They will rightly be blamed or credited with whatever they do.  Or don’t do.  At least by voters.  The media will criticize Republicans for simply existing, but fortunately, they don’t decide elections, as they painfully learned last year.

There is no argument that Obamacare is failing.  As some suggested, it could be allowed to continue and implode, but the resulting chaos will be hung like an electoral noose around Republican necks.  They can fix it.  Hand-wringing and indecision are not fixes.

It comes down to three options.  One is to do nothing, enabling the continuing destruction Obamacare is wreaking on Americans.  Two is continuing the no-win debate on a replacement option that has no hope of passing Congress – or, if something does squeak through Congress, it being little better than the mess it’s replacing.  Three is to use the congressional majority, nuking the filibuster and Byrd Rule if necessary, repealing Obamacare entirely.

That would leave Congress with a clean slate – an opportunity not to fundraise and kiss the rear ends of lobbyists and donors, but to do their jobs and legislate.  All members of Congress have given interviews and speeches, debated the issues.  Surely, they have ideas on how to deliver health care to the American people.  Time to do it.

If they fail, voters may say “meh” in 2018 and beyond.  Any guess what Democrats will replace Obamacare with if they are handed the reins of power?  Single-payer.  Medicare for all.

Let’s go, congressional Republicans.  You wanted to be put in the game.  Time to show America why you are better on the field than on the bench.

Brian Joondeph is an ophthalmologist based in Denver. He is a frequent contributor to THCB. 

5 replies »

  1. I’m not sure the GOP wants to repeal Obamacare. Yes it’s a shame that they had nothing ready to go despite having Congressional majorities for much of the past 6 years. They didn’t expect Trump to win (many didn’t want him to win) and didn’t think they would have to actually govern having a majority in Congress and controlling the WH.

  2. HSA pro/con quibbles aside, the political incoherence on this issue — on both sides of the partisan divide — remains pretty poignant. In general, NO amount of calling a commercial (dubious value-add) 3rd-party intermediated pre-payment scheme “insurance” will make it so. Y’know, the totemic lament — “what good is having ‘insurance’ if you can’t use it?”

    I’ve been with MetLife for, like, FOREVER for my auto coverage. Have yet to file a claim. That’s “insurance.” My (affordable) hedge against ruinous calamity.

    But, of course, we will continue to conflate things when it comes to health care. And we will continue to eschew rational net improvements, so wedded are we to our respective ideological Perfectionism Fallacy catechisms.

  3. HSAs = Big deductibles. That has been a primary criticism about Obamacare from the right. How is that getting resolved if you want to expand them?

  4. The most pathetic part of this story is that the R’s have been freaking out for years about ACA and then when the country hands them Congress and Presidency, they are the gang that can’t shoot straight. They have had at least 6 years to get a real plan in order. Obviously there was no plan. As MDs, we are begging to the remove regulatory burdens and buzzword care, like VBC, MACRA, MU, etc. But Tom Price and Veema appear to be yet again TONE deaf about our struggles. Its VERY clear that the R’s are lacking vision, leadership and courage. The only thing that would have been worse would be the D’s bright ideas of the prior administration. So as an MD and citizen, I’m disgusted by Washington DC and am holding out hope for a 3rd party that arises from this mess.