There are two ways to tell the story of the Affordable Care Act and the Republican efforts to repeal the law that has brought our country’s uninsured rate to its lowest point ever.
There’s data. And there are people.
The nonpartisan Congressional Budget Office examined the impact that repeal would have on health insurance coverage. The numbers are staggering and terrifying.
Eighteen million people would lose health coverage in the first year. The number would increase to 32 million by 2026. The research does not score a replacement, because no real replacement has been proposed with enough detail to judge its impact.
Writing in The Washington Post, two health care researchers parse the numbers even more. Roughly 44,000 people a year will die if the ACA, also called Obamacare, is repealed without a replacement.
The numbers are so large, the impact so devastating and widespread, that they are difficult to believe. There’s a truism in public policy about big numbers. When they get big enough, they’re difficult to perceive.
But behind each of the big numbers about health care, there are real people.
People who are ill are facing an uncertain future, even under the best of circumstances. A person I know is fighting cancer. He’s covered through Obamacare. (I’m not using his name because the last thing he needs is a bunch of Trumpistas on the attack.)
“It would seem that I, with my fingers desperately grasping my ACA coverage as I slip slowly through the tunnel of cancer world, am in a very leaky lifeboat. I have always worked hard, played by the rules, paid my own way, served my country and my community. Now I am about to have a death sentence delivered to my door by my very own government. Tough to swallow. Really tough.”
He lives in Maine. You may know him. You probably know someone like him.
The political disagreement over the Affordable Care Act is about the appropriate role of the government in providing health care and about who, ultimately, pays.
Broadly speaking, Republicans would limit the government’s role as much as possible, including rolling back successful programs like Medicare and Medicaid, and they would force as many people as possible into the private market.
Democrats can be put into two categories: People who support universal, single-payer health care, similar to what our neighbors in Canada have, or a hybrid that combines private markets with programs like Medicare, Medicaid and the Affordable Care Act.
The ACA boosted coverage by expanding access to health coverage for low-income families through Medicaid, called MaineCare in Maine, and through subsidies to help purchase insurance on the private market.
Gov. Paul LePage has refused to expand Medicaid, costing the state hundreds of millions of dollars and needlessly jeopardizing public health. Five times he’s vetoed legislation, supported by both Democrats and Republicans. Now, a group of citizens have collected enough signatures to force the issue and place expansion on the ballot — even with the uncertainty of the law down the road.
Obamacare has been effectively demonized. It was a political albatross, hurting Democrats up and down the ticket. But now that Republicans control the levers of power in the federal government, voters are looking upon the law with new eyes.
A NBC News/Wall Street Journal poll released last week found that 45 percent of Americans support Obamacare, compared to 41 percent who don’t. And half of all respondents said they have no confidence that Republicans will come up with a better idea.
Voters are pretty clear about what they don’t like about Obamacare. And it doesn’t match the policy argument that most Republicans are making.
In focus groups conducted by the Kaiser Foundation, voters said they worried about rising premiums, deductibles, copays and drug costs. And, they said, surprise bills for services they thought were covered made them really angry. They don’t like insurance companies, either.
From the limited details we’ve seen about replacement plans, all these problems are likely to get worse.
Sen. Susan Collins, working with Sen. Bill Cassidy, this week introduced the outline of an ACA replacement, which would allow states to keep Obamacare if they want, completely opt out or set up a system that combines Health Savings Accounts and health insurance plans with high deductibles.
So far, the plan hasn’t garnered support from many Republicans or Democrats. It appears to leave in place the fees and taxes that fund Obamacare and use them.
The plan struggles from the central policy argument about health care by trying to create a choose-your-own-adventure menu that mixes a heavy federal hand with a hybrid system and a doomsday option, where states just opt out, leaving their residents out of luck and largely on their own.
As the left-leaning Center on Budget and Policy Priorities sees it, the plan likely puts at risk low-income families and people with pre-existing conditions.
There are major concessions in the Collins plan meant to earn Democratic support. While the details are unclear, it appears to be a good-faith effort. It’s at least a starting point.
What seems impossible is for the plan — any plan — to give Republicans and voters what they both want, because they want very different things.