Obamacare — back from the dead? Why Donald Trump doesn't dare pull the plug on the ACA

The ACA may be A-OK after all: Trump is walking back his promise of repealing the Affordable Care Act for a reason

Published November 14, 2016 1:00PM (EST)

Supporters of the Affordable Care Act react with cheers as the opinion for health care is reported outside of the Supreme Court in Washington   (AP/Jacquelyn Martin)
Supporters of the Affordable Care Act react with cheers as the opinion for health care is reported outside of the Supreme Court in Washington (AP/Jacquelyn Martin)

After the surreal fog of Donald Trump's victory had lifted; after the physical discomfort that accompanied the visceral disgust at what half of the country had wrought on Election Day 2016, something occurred to me that, even while staring into the abyss, made me smile. You might've noticed how the 60 million voters who chose to "make America great again" chose to do so by apparently repudiating the social liberalism of the last eight years. Looking at various exit polls, it's becoming increasingly obvious that white voters, men and women both, cast their ballots against an America that seemed to be leaving them behind. They believed it was a repudiation of Black Lives Matter and the culture of political correctness. It was a repudiation of tolerance and equality. It was a repudiation of "uppity" blacks, "uppity" same-sex weddings and the accompanying anti-Leviticus cakes; of free contraception and transgender people in bathrooms.

It dawned on me, however, that Black Lives Matter will still exist in Trump's America. PC culture will still exist in Trump's America. Same-sex weddings will still exist. Much of the cultural shift that occurred during the Obama years will continue, and, indeed, grow louder and more organized under President Trump, despite the election results and the wildly irresponsible votes of 60 million Americans who thought they were killing it all. Trump won't be capable of making it go away, at least through traditional means, just as Presidents Johnson and Nixon, with all of their pre-Watergate executive latitude, were ultimately crippled by the anti-war protests in the late 1960s and early 1970s.

However, while all of those things will remain, it's entirely possible that Trump voters aided in the destruction of their own healthcare. Indeed, perhaps the first item on Republican agenda will be to implement massive changes to Medicare and the Obamacare health insurance policies held, in part, by Trump voters and many of their loved ones -- friends and family alike.

Some 20 million Americans, myself included, will be stripped of our policies, and left to either die due to accidents or disease, or to go bankrupt trying to pay for it out of pocket. Meanwhile, if Obamacare is repealed, rates and deductibles will return to their prior cost-curve trajectories -- spikes in rates that'll far outpace the more modest increases seen with the law in place. Couple that with a return to what's called "rescission," in which health insurance companies can legally strip people of their insurance after they get sick -- a practice banned by Obamacare — along with sick people flooding back to emergency rooms, and Trump voters will have made healthcare far worse than it's ever been, after the repeal.

Knowing there are around 20 million enrollees in policies acquired via the Obamacare marketplaces, but there are 60 million Trump voters so far, it's fair to observe that many Trump voters aren't even using Obamacare, nor is the law harming their own lives or their own healthcare via their employers. Yet these 60 million Americans have chosen to "make America great again" by stripping me and 20 million others of healthcare they've never had to bother with. But I suppose the law's nickname has the word "Obama" in it, so it has to go. I'm not sure how any of these people can look their friends and family in the eye, knowing that some of them will lose their healthcare due to the votes for Trump and a GOP Congress.

It's more than heartbreaking how dads voted to take healthcare away from their adult children; how moms voted to force their grown children into shitty catastrophic plans that cost a fortune and cover nothing; how grandparents voted to force their kids and grandchildren to potentially go bankrupt trying to pay for cancer care or a near-fatal accident. All because they felt pissed that it's the 21st century and not 1957. It's clear that 60 million Americans cast cruel, heartless ballots that will irreparably harm the people they claim to love.

So fanatical was their rage, they ended up voting for a berserker-in-chief who, by the way, might also undermine their Medicare as well. It turns out Speaker Paul Ryan plans to work with the Trump administration to make significant changes to Medicare, including at least a partial privatization, leaving older Americans to the whimsy of private health insurers, as he explained in a Fox News Channel interview:

“When Obamacare became Obamacare, Obamacare rewrote Medicare, rewrote Medicaid, so if you’re going to repeal and replace Obamacare, you have to address those issues as well. What people don’t realize is that Medicare is going broke, that Medicare is going to have price controls. Because of Obamacare, Medicaid is in fiscal straits. So you have to deal with those issues if you’re going to repeal and replace Obamacare. Medicare has got some serious problems because of Obamacare. Those things are part of our plan to replace Obamacare.”


"Medicare, meanwhile, would move toward a 'premium support' model where seniors would choose a private health plan, and Medicare would pay at least a portion of the premium. The plan does not describe cuts in coverage, but these proposals have been previously floated in the context of long-term federal spending reductions."

Ryan's hyperbolic language aside, Obamacare's impact on Medicare has been overwhelmingly positive. As Jonathan Chait writes:

The Medicare trust fund has been extended 11 years as a result of the passage of Obamacare, whose cost reforms have helped bring health care inflation to historic lows. It is also untrue that repealing Obamacare requires changing traditional Medicare. But Ryan clearly believes he needs to make this claim in order to sell his plan, or probably even to convince fellow Republicans to support it.

Meanwhile, more than 100,000 Americans signed up for insurance policies through Obamacare exchanges on the day after Trump's victory, November 9 was the biggest day for enrollments this cycle. Get it while you still can before your Trump voter friends and family, who don't even use the law, tell you you're not allowed to have insurance any more.

Before we wrap up, there's actually some good news here. During an interview with The Wall Street Journal, the president-elect surprised everyone by walking back his pledge to completely repeal Obamacare. Trump said that he'd like to keep the sections of the law that require insurers to cover people with pre-existing conditions, as well as children who'd like to remain on their parents' policies until age 26. But here's the wrinkle. If Trump makes good on his pledge, he'll also have to retain the unpopular individual mandate. The insurance industry will never accept enrollees with pre-existing conditions without the mandate, otherwise people will simply sign up for policies as soon as they get sick or injured -- gaming the system. But wait, there's more. If he keeps the pre-existing language and the mandate, he'll also have to keep the subsidies and Medicaid expansion or else low-income Americans won't able to afford their mandatory policies. The pre-existing condition language, which is wildly popular and Trump knows it, demands that the rest of the law remain in place.

The other good news is the filibuster. Senate Democrats can successfully filibuster any and all attempt to repeal the Affordable Care Act before it moves on to the White House for Trump's signature (how surreal is that?). The Republicans only hold 51 seats, not nearly enough for cloture.

The bad news is a seldom discussed parliamentary loophole known as "reconciliation." Any budget-related aspects of Obamacare could be repealed with a strict majority vote of 51. This means the subsidies and the Medicaid expansion could be repealed, effectively bleeding the law to death. It's possible, though, that one or two moderate Republicans could join the Democrats to block a reconciliation vote. Unlikely, but possible. Nevertheless, reconciliation is one of several reasons why the left would do well to politically backstop moderate Senate Republicans along with Democratic senators. Twenty million Americans are depending on it. But, again, none of this will matter anyway if Trump insists upon keeping the pre-existing condition section of Obamacare.

Trump could use executive orders to undermine the implementation of the law at the cabinet department level. This could include the revocation of the Health & Human Services federal exchange, Healthcare.gov. Additionally, members of Congress and staffers, Democratic and Republican alike, could lose their premium-sharing, in which the federal government, their employer, covers 70 percent of the monthly premium costs, forcing them to pay the entirety of their premiums out of pocket. One of many hazards for actual members of Congress if they choose to repeal without an adequate replacement.

One way or another, Obamacare isn't extinct yet, but it's definitely endangered. It's just one of many colossal side-effects of Trump's shocking Electoral College victory. My hunch is the buyer's remorse will be significant, especially as soon as healthcare is on the table early next year. And there will be millions of Trump voters, especially the older ones, who will wonder what the hell they got themselves into. But this is what happens when voters are driven to the polls by meanness and inchoate rage rather than thoughtful consideration of the myriad downsides. Nicely done, Trump voters.


By Bob Cesca

Bob Cesca is a regular contributor to Salon. He's also the host of "The Bob Cesca Show" podcast, and a weekly guest on both the "Stephanie Miller Show" and "Tell Me Everything with John Fugelsang." Follow him on Facebook and Twitter. Contribute through LaterPay to support Bob's Salon articles -- all money donated goes directly to the writer.


Related Topics ------------------------------------------

Donald Trump Medicare Obamacare Paul Ryan The Affordable Care Act