Friends of Obamacare, horrified that the Supreme Court has taken a case that could blow up the federal health insurance exchanges, should recalibrate their dread. While the health reforms were safely humming along, there was little political price for demanding their demise. Thanks to the Supreme Court, now there is.
Years of carpet-bombing assaults on Obamacare have left many Americans thinking that they don't like the Affordable Care Act. But close down the federal exchanges covering 6 million people (so far) in 36 states and they may think otherwise. With a vengeance.
Here are the stakes in King v. Burwell: Should the justices strike down subsidies for coverage in the federal exchanges, only the very sick would hang in. That would be the end of the federal exchanges.
Donald Taylor, a health policy expert at Duke University, likens the Obamacare attackers to a dog chasing a car. "What's the dog going to do if it catches the car?" he said to me.
Subsidies would be untouched in the 12 or 14 state-run exchanges (depends on how you define them), the majority of which are in blue states. Red-state politicians — oddly the biggest foes of a law that in effect transfers tax dollars from high-income liberal states to poor conservatives ones — would have a mess on their hands.
"Some Southern states will be back up to 20 percent uninsured," Taylor said, "and that doesn't sound politically stable."
The solution for Republicans would be a plan B. But they don't have a serious plan B.
Republicans do have a proposal of sorts, composed early last year by three senators — Richard Burr of North Carolina, Orrin Hatch of Utah and now-retired Tom Coburn of Oklahoma. But it was written mainly as a political document with which to hit Obamacare over the head during the 2016 campaign — not as a ready-to-plug-in substitute.
Let's look at the Republican plan that we aren't supposed to examine too closely.
For starters, it would empower private insurers to play a bigger role in the relationship between you and your doctor — encouraging them to shrink the network of doctors and hospitals you may visit. So much for "choice."
It also would cut government subsidies for many working stiffs who earn too much to claim poverty but too little to afford decent private coverage. And it would enable insurers to charge older people far more for their insurance. Obamacare lets them charge three times as much. The Republican plan would let them charge five times as much.
Gone would be the minimal coverage standards. That means the insurers could more easily deny payment for services that Obamacare considers basic. For all these gifts to private insurers, the industry actually prefers Obamacare because its subsidies create many more customers for their products.
The Republican replacement plan (as written so far) contains lots of other controversial elements pretty much ignored because few have taken it seriously. For example, it would tax employer-sponsored health benefits. (Obamacare's "Cadillac tax" on luxurious coverage does some of that, for which it continues to take a beating.)
A group of conservative economists, led by Douglas Holtz-Eakin, has scored the Burr-Hatch-Coburn plan and claims that it would cut deficits by $1 trillion. These are reputable economists, Taylor says, but the text they were working with was "incredibly vague" on where the cap on the taxes would be put.
"The score is a number, and the text on which they did the score was ambiguous," he said. "It shows just how hard this is."
So now Obamacare won't be the only pinata in town.
The Supreme Court will take up King v. Burwell in March. We do live in interesting times.
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