The politics of the ACA replacement

Republicans are deciding now which way to play the CBO report.  

Embrace it--it is good news.  People have freedom 

Attack it--the CBO lies.  

The Congressional Budget Office just released its analysis of the proposed Republican replacement.   It concluded that some 6 million people would lose coverage.  Or 15 million.  Or 22 million, if you count out ten years.

GOP response:  Embrace the CBO report.    Paul Ryan was ready with an explanation. "I'm pretty encouraged by it," Ryan said in an interview on Fox.   People would lose coverage because they did not want coverage.   Of course the CBO is going to conclude "if we're not going to make people do something they don't want to do, they're not gonna do it."

And there was good news in the report.   By reducing the number covered by insurance and the Medicaid expansion (i.e. covering the near-poor as well as the very poor) lowers costs to taxpayers.

Alternative GOP response: Attack the CBO report.  Newt Gingrich is saying it loudly and clearly: Abolish the CBO.  They are dishonest.  They are wrong.

Gingrich:

"It is corrupt, it is dishonest, it was totally wrong on Obamacare by huge, huge margins," Gingrich said. "I don't trust a single word they have published and I don't believe them."   Reminded by the Fox host that the CBO head is a Trump appointee, Gingrich said, "I couldn't care less."

Watch:  Gingrich interview

Donald Trump, too, is taking this tack, in the words of Fox News he is "firing back" at the "difficult numbers for the White House."   Trump accused the media of focusing on the positive parts of Obamacare and ignoring its "major problems."

Democrats are taking political comfort in what most news outlets call a devastating CBO report.   Senator Chuck Schumer called the numbers a "nightmare" that delivered "a knockout blow" to the GOP replacement plan.  

Warning to Democrats:  There are conflicting values being argued here.  Democrats are arguing the premise that more people getting Medicaid expansion or affordable insurance is good.   Republicans are not arguing that point.  They are arguing their points:  that freedom is better than compulsion and that thrift is better than spending.   Democrats could lose this fight because for a great many Americans the people who might be getting expanded Medicaid or insurance subsidies are people other than themselves.  

There is widespread suspicion that some people getting help are lazy or imprudent people gaming the system.   The significant attention to the "lottery winner loophole" makes that point: Obamacare's rules allowed some people with assets but low "income" to qualify.  The working poor live alongside the non-working poor and both groups are acutely aware of who is getting what benefits, whether they themselves are paying for it, and whether it is well deserved.  Democrats can not assume that more healthcare access is better politically.

Recommendation for Democrats:  A safer approach for Democrats is to note that uninsured people do, in fact get care, often very expensive care, because they are treated late and in the most expensive format: the emergency rooms of hospitals, the health care of last resort.   The best political tack for Democrats is to look at the effect of reduced Medicaid expansion and reduced insurance for the working poor on health care providers especially hospitals.   Every middle class person sees the hospital as a public good, something they personally may use someday.  Uncollectible healthcare costs endanger hospitals.   Preventive medicine left undone does not save money, it costs money.  It gets paid in revenue shifting for providers rather than in taxes.


Democrats saying that poor people need more help is an argument that runs headlong into a widespread bi-partisan voter fear that other people are getting goodies from the government that hardworking and deserving people like themselves are paying for.   That argument helps Republicans.   The soundest Democratic response is to say that uninsured people get paid for in the most expensive way possible and that hospitals make up for the uncollectible fees by jacking up the charges on the people who have employer paid health insurance.  

In short: Medicaid expansion and health insurance saves regular people like yourselves money.  Yes, it costs millionaires more, but they can afford it.  Obamacare is financially prudent.   And, oh, yes, it also saves lives.

The good news for Democrats is that this is true and the hospitals and health care providers know it and are saying it.