For six years, the Republican position on the Affordable Care Act has been simple:
Repeal and replace.
This was the battle cry even though, as Oregon Sen. Ron Wyden (along with a lot of other people) points out, “They have never, after all these years, put out a real replacement.”
Now, Republicans are in a position to enact their slogan, and last week Senate Majority Leader Mitch McConnell and incoming White House chief of staff Reince Priebus reaffirmed that repeal would be a first priority – still with no sign of what replacement would look like. So the policy appears to be Repeal and Delay, voting down Obamacare immediately and promising their replacement plan in a few years.
Or as Wyden defines it: Repeal and Run.
And Oregon should be the first place to be running.
No state has bought into the Affordable Care Act more than Oregon (except for the part about designing a workable state web site). Oregon has applied for waivers and additional funding to greatly expand the Oregon Health Plan, its version of Medicaid, and to align the ACA with Oregon’s own inspiration of coordinated care organizations. Nearly 400,000 Oregonians have come into Medicaid under the Affordable Care Act’s expanded eligibility, and more than 200,000 have bought insurance, many with subsidies, from the health.gov web site.
Already, the costs of Oregon’s enthusiastic embrace of Obamacare are helping to put the next legislature into a deep fiscal hole. Oregon is seeking another $1.2 billion from the feds over the next five years, an appeal that may be less warmly received than the state might have hoped before election day.
And that’s before Congress and the Trump administration pull the rug – or maybe the examining table – out from under the program. The hole gets even deeper if House Speaker Paul Ryan achieves his goal of rolling Medicaid and other programs into a sparsely funded block grant.
And change could be coming faster than you can get a doctor’s appointment.
“Probably around January 3 or January 4, the repeal and run strategy begins,” predicts Wyden, as part of a budget reconciliation package that needs only a simple Senate majority, not the 60-vote supermajority usually needed to pass legislation. Reconciliation, he forecasts, will be “a Trojan horse for providing a tax break for the most fortunate and higher insurance costs or no insurance for the rest.”
Wyden, as ranking Democrat on the Senate Finance Committee, which will handle a health policy overhaul, puts Oregon at the front of the issue in another way – along with GOP Rep. Greg Walden, new chairman of the House Energy and Commerce Committee, the bill’s route through the House.
But after six years of pledges to repeal and replace, Wyden doesn’t expect to see a complete replacement package soon. “It’s like the marquee of an old movie theatre that always says ‘Coming Soon,’” he suggests, “and the movie never quite shows up in your neighborhood.”
There may not be much more clarity coming from the president-elect, whose promise is to replace Obamacare with “something terrific.”
Yet a vote to repeal Obamacare now and replace it later, or repeal it two or three years in the future, will have its own problems. Repeal might take out Medicaid expansion and the subsidies, and maybe the legal requirement for everybody to have insurance. Some Republicans have been saying friendly things about Obamacare’s ban on insurance providers refusing to accept customers with expensive pre-existing conditions, but without the individual mandate, the economics of that guarantee collapse.
And insurance and medical providers, seeing the exchanges coming to an end shortly, might well decide to get out immediately.
“Once you vote for repeal,” says Wyden, “it starts a death spiral.”
An unfortunate image for a medical care program, but probably an accurate diagnosis.
Oregon has a lot riding on the outcome, but Lynne Saxton, director of the Oregon Health Authority, stresses the arguments the state can make, and points out, “The governor has been very clear that we’re not going to reduce benefits, and we’re not going to remove people from care.”
It’s particularly crucial in a state where some counties have as many as 39 percent of residents on Medicaid.
To keep things going, of course, it would be useful for Oregon to get both the $1.2 billion it’s seeking and a five-year extension of its federal waiver allowing the state to continue to run programs its way, goals that Wyden has been down to Salem to discuss with the governor and legislators.
Saxton says she’s been listening to the news out of Washington, and “I don’t hear a lot of people saying, let’s just take health care from people. What I hear them saying is, let’s be more efficient and effective.”
On that subject, she says, Oregon has a lot to offer, including a health cost growth rate half the national average, a one-third reduction in hospital readmissions and cutting avoidable emergency room visits in half.
“It’s going to be a challenge,” says Saxton about Oregon’s maintaining its system, “but I think we have the data to support it.”
If the reality is Repeal and Run, Oregon will need to run pretty fast.
NOTE: This column appeared in the Sunday Oregonian, 12/18/16.