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Affordable Health Care: What's Next?

As Republican legislators stepped aside and defected from party efforts to overhaul the Affordable Care Act last week, Cal State Fullerton experts on politics and health care grew curious about the fate of the promised repeal.

The Affordable Care Act of 2010 incorporated all the best ideas from previous state and local experiments to expand health insurance in the most equitable and cost-effective way that was politically possible at the time, says Shana Alex Charles, assistant professor of health science. "And it worked — since the law was enacted, the United States cut the uninsured rate nearly in half, down to about 11 percent of the population," she added.

Predictably, many among the tens of millions who now have coverage that would be threatened by a new bill or a repeal have voiced concern directly to their state representatives. And, forthright or flawed, the repeal failed — for now.

Here, Charles and political science professors Stephen Stambough and Matthew Jarvis piece together the replacement plan's downfall and predict what might happen next.

Why did the effort to repeal and replace the Affordable Care Act fail?

Stambough: The GOP never reached consensus on an alternative plan during the years that Obama was president. There are parts of the GOP coalition that do not agree with each other on an approach for an actual, positive policy. The moderates do not agree with the ideologues. In addition, those senators with gubernatorial experience have a different perspective because they see the actual impact of the policy in their states.

What must the Republican party do to make this bill sit well with its constituents?

Jarvis: The answer depends on what you mean by 'constituents.' For the Republican base voters, they've been fed a steady diet of 'Obamacare is evil.' So, passing something to claim victory that doesn't actually change much would work. For their constituents in their districts, they would likely need to keep elements like the pre-existing conditions restriction, keeping children on parents' insurance plans until 26, no lifetime benefits limits, and no age rating. While the individual mandate is unpopular, it's the glue that keeps the insurance exchanges from eventually going into 'death spirals' that only have chronic patients in them. In Republican districts, the opioid epidemic is a big concern, so some funding for that would be helpful. But, the large Medicaid cuts to pay for tax cuts for the wealthy won’t be popular. If the GOP actually wrote a bill pushing general conservative ideas about health care, like competition across state lines and health savings accounts, they might be able to sell that as an improvement. But, no major element of the social safety net has ever been removed. Once provided, people come to rely on those things, and get very angry when you try to take them away.

What's likely to happen next?

Charles: It's not clear whether Republicans will be tethered to their past promises of 'repeal and replace,' or will seize this opportunity to move forward and craft a new proposal that will build on the ACA's success to protect coverage levels while lowering costs both at the macro- and family-levels. I very much hope, for the good of the nation, that the latter will be the case. Letting the ACA fail through lack of good implementation or outright sabotage will just lead to bigger Democratic waves in 2018 and 2020, fueled by the suffering of the nearly 17 million estimated to lose their coverage during 2018.

What lessons can be learned from this?

Stambough: Campaigning is not the same as governing, and governing is what should matter.

Jarvis: There's more to legislating than position-taking. Actually crafting laws takes hard work and compromise.

Charles: I fervently hope that Congress learns the benefit, finally, of pursuing bipartisan goals simultaneously. We've had decades of health insurance expansions that didn't go as far as Democrats would like, but that have still cost more than Republicans can stand. The only way to address both issues simultaneously is to dramatically reduce costs through moving to a universal coverage system. I believe that we will make dramatic steps toward this goal within the next five years.

How might the administration experience the same division and inability to make change with the president's tax reform efforts?

Stambough: Different policies mean different politics. This experience does show that the GOP governing coalition is not unified. In a large democracy like ours, no governing majority should be fully unified; however, that can be frustrating for policy development. Tax reform is big, but it is different. It is easier to give out 'goodies' in the tax code in return for votes, so I would expect some significant trading to take place for that one, if they can get to it.

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