The Health Reform Catch-22

February 28, 2017

Ever since the election, the President and members of his party in Congress have been focused on one of the central promises nearly all of them made in their campaigns, to “repeal” Obamacare and – perhaps – to “replace” it as well.

Repealing and replacing Obamacare has proved as difficult to accomplish as passage of health reform was in the first place.  After all, it took President Obama about 15 months to get the Affordable Care Act (ACA) through Congress, and sign it, and to accomplish this he had to use nearly all the political capital he had, and even then it passed with literally no votes to spare when Obama had filibuster-proof majorities in the Senate and House.

Also, passage of national legislation to achieve anything close to universal coverage took about 100 years, since Teddy Roosevelt was the first President to advocate for universal coverage in the 1910s, and it took eight attempts at the national level before Obamacare passed.

But now that President Trump and the GOP have gained control of the Presidency and Congress, a political reality is kicking in.  That is, Trump and the GOP face a vicious Catch-22 as they attempt to write a health reform plan.  In particular Trump has said that "everybody's got to be covered", and that his plan will "take care of everybody" and that "government is going to pay for it" by providing "great plans, lots of competitions" that lowers costs.  So they have promised or have these goals:

  • Do not increase the uninsured;
  • Lower costs for private insurance plans;
  • Replace Medicaid expansion, and lower Medicaid costs;
  • Eliminate mandates, especially the “individual mandate”;
  • Strengthen private health insurance markets;
  • Keep insurance reforms (e.g., bans on existing conditions) and popular coverage expansions (e.g., adult dependents up to age 26), and
  • Eliminate tax increases enacted to pay for the ACA.
By now most if not all of the GOP members of Congress realize that achieving ALL of these goals is impossible.  For example, it is impossible to repeal the taxes enacted to pay for the ACA and have enough money left so that the same number of people are covered by insurance after passage of any reform legislation, since the subsidies in the ACA are what made it possible for the poor and near-poor to afford coverage. To cite another example, the stability of insurance markets will be severely strained if the mandate is repealed along with subsidies to buy coverage.

These are the huge policy dilemmas the GOP faces, the Policy-Catch-22.

But even beyond this, the POTUS and Congress face the dilemma of how to leave other provisions of the ACA intact – such as the closing of the so-called “doughnut hole” for Medicare recipients with prescription drug plans; the expansion of preventive coverage for Medicare; payment and delivery system reforms.

And these are just the daunting policy dilemmas, saying nothing of the political dilemma the GOP faces as it ponders replacing the ACA.  In particular, no matter what policy proposal they put forward, they can count on solid opposition from all or nearly all Democrats. Thus they need every GOP vote.  However, some members of the GOP are willing to repeal Obamacare without replacing it; some seek to scale back the ACA and limit it but not repeal it outright (e.g., Libertarians); some seek to fiercely protect provisions such as the expansion of Medicaid, especially if they represent a “red” state that expanded Medicaid (e.g., IN, AZ, NJ, OH); some balk at eliminating provisions such as expansions of preventive care for women.  

Leader McConnell can afford to lose only 2 votes, if he loses more votes he cannot pass legislation in the Senate, assuming he gains no Democratic votes. And he will need to garner 60 votes to even bring some parts of a “repeal and replace” legislation up for consideration, given the Senate filibuster rules. Although Speaker Ryan has control of more votes in the House, even he can only lose 24 votes (roughly 10% of the GOP caucus) before his 241-194 margin slips below a majority, and as Speaker Boehner will tell him the difficult “Freedom Caucus” is a bigger problem for him is a bigger problem for him than is a solid Democratic opposition.

In short, as President Trump recently said, health policy is “unbelievably complex subject.”  Indeed it is, as many of us knew.


New estimates of uninsured to be released 9/13/16

September 13, 2016
Another milestone in the release of federal data will come Tuesday, 9/13/16 and Thursday 9/15/16 when the U.S. Census Bureau releases results from two surveys that are widely used to estimate the number of people in the U.S. with and without health insurance.

The Bureau will release estimates from the Current Population Survey and the Annual Social and Economic Supplement (CPS/ASEC) and the American Community Survey (ACS).  The former survey provides national estimates of insurance coverage wi...

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Health Insurance Marketplaces: Premium Trends, 2014-16

May 12, 2016

There has been a great deal of attention recently to the premiums in the Health Insurance Marketplaces (HIMs), and the potential shape of the marketplaces in 2017. The recent announcements by some insurers that they may pull back from their role in the marketplaces authorized by the Patient Protection and Affordable Care Act (ACA) has fueled this interest, along with the annual period when insurers submit their preliminary bids for premiums in the marketplaces, with fears that the growth in p...

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IMPORTANT MILESTONE: Insurance, uninsurance estimates for 2014 to be released Wednesday 9/16

September 15, 2015
A big milestone in the release of federal data will come on Wednesday when the U.S. Census Bureau releases results from two surveys that are widely used to estimate the number of people in the U.S. with and without health insurance.

The Bureau will release estimates from the Current Population Survey/Annual Social and Economic Supplement (CPS/ASEC) and the American Community Survey (ACS).  The former survey provides national estimates of insurance coverage with breakdowns by demographics, inco...
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Supreme Court upholds Obamacare again

June 25, 2015

The Supreme Court decided today on the “Obamacare” case, called “King v. Burwell” and ruled in a 6-3 decision to support the Administration’s position on the law, that subsidies should be allowable in federal marketplaces.  The Chief Justice Roberts and Justice Kennedy joined the four liberals (Breyer, Ginsburg, Kagan and Sotomayor) in the decision.  Find the decision here.

The decision is important for the continued implementation of the Affordable Care Act, and means that perhaps a...

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Awaiting SCOTUS case on subsidies: liberal justices on majority opinions all year

June 9, 2015

Today I was looking at a New York Times article, which listed how the justices voted on "major" cases this session, and one thing struck me -- on each and every case all four so-called liberal Justices (Ginsburg, Breyer, Kagan and Sotomayor) voted in the MAJORITY on each and every case, sometimes joined (of course) by 1-5 other justices, most frequently Kennedy, Roberts.  The three most conservative justices (Thomas, Scalia, Alito) were least often on these cases.

This led me to think about th...
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Is the Sky Falling? Let's Wait

May 27, 2015
So it's that time of the year on the calendar when private insurers who offer plans in the Health Insurance Marketplaces (HIMs) start to submit their "rate bids" for the next year, and some reporters have obtained information on these bids.  This is leading to some rather hyperbolic headlines, and reaction, about how the marketplaces may be falling apart under a cost explosion.  In fact, this is an annual experience that needs to be calmly understood, and we need more time -- and data -- to u...
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Growth in Missouri Medicaid 3.5% since ACA began

May 6, 2015
As others who follow trends in Missouri Medicaid enrollment know, Missouri is a state that has shown sluggish growth in Medicaid enrollment over the last year, even while other states have seen significant growth -- including states that have also not expanded Medicaid (experiencing the so-called "Woodwork" effect).  In fact, for several months, the growth in Medicaid in Missouri was flat or negative, and Missouri had one of the slowest rates of growth in Medicaid in the country.

It appears fr...
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Backlog facing Missouri Medicaid nearly erased

May 6, 2015

There is good news for Missouri’s Medicaid program.  In the last few months, the program (called MOHealthNET in Missouri) has really turned the corner on a challenge the program faced in the recent year – a backlog in processing applications to the program.  However, in the last 4-5 months, concerted efforts by state workers, working hard with many around the state has led to a huge drop in the backlog.

As this figure shows, the number of days it is taking for an applicant to Medicaid to...

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"Grubergate" (II): The contracts

November 18, 2014

In the latest attempt to attack Obamacare, opponents think they have a juicy new target, Prof. Jonathan Gruber, from MIT.  In addition to pulling his quotes from academic musings out of context, the opponents have a new line of attack: that supposedly Gruber "netted" millions of dollars in contracts from the federal government (the Obama administration) to do his work.  The impression left, often said directly, is that Gruber himself was paid these dollars, or that the total dollars from the ...
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About Me

Timothy McBride Timothy D. McBride, Ph.D. is a Professor at the Brown School, Washington University in St. Louis. Here you can find musings on health policy and other issues. Opinions are my own, and not those of my employer. Contact: