The Story Thus Far: The Supremes are expected to hand down a decision in King v. Burwell this month or the next. If the Court sides with the plaintiffs, the subsidies for health insurance purchased through exchanges would be eliminated in 34 states, causing about 7.5 million people to lose coverage on the spot. The decision could bring about the catastrophic failure of the ACA.
Republicans are angry with the White House for not creating a “Plan B” to make some provision for the 7.5 million. Of course, if Republicans in Congress gave a hoo-haw about the 7.5 million, it would be the easiest thing in the world to simply amend the ACA to make it clear the law will provide subsidies to all states whether they created their own exchanges or not. The House has managed to vote to repeal Obamacare more than 50 times already, after all; they could divert their attention to a simple fix.
There is an ongoing debate whether a decision to strike down exchange subsidies would hurt Dems or Republicans worse. In a sane world it ought to hurt Republicans, but many have pointed out that voters in the affected states probably don’t know doo-doo from doughnuts — else they wouldn’t be saddled with a bunch of loser wingnuts in state government — and would blame Democrats when their premiums are jacked up.
Anyway, the White House position is that any justice who votes to end exchange subsidies would be a political flunky and damnfool idiot, and they’re banking on at least five justices not being damnfool idiots. We’ll see. But the White House is making no plans.
Republicans are making typical Republican-type plans, which means they are trotting out hazy concepts that won’t work but can’t come up with anything concrete. Jonathan Cohn explains the problem:
Republican leaders in Congress have been promising to craft a detailed Affordable Care Act alternative ever since President Barack Obama signed the law in March 2010. But while Republicans have found time to vote on repealing the health care law more than 50 times — and have worked hard, as they did on Tuesday, to pass modifications that would benefit powerful special interests like the medical device industry — they’ve yet to move a single Obamacare alternative through committee and to the floor. Nor has any committee with relevant jurisdiction held even a single hearing on how to handle the aftermath of a potential Supreme Court ruling that wipes out tax credits in two-thirds of the states.
(For a thorough and thoroughly amusing chronicle of past GOP promises to craft Affordable Care Act alternatives, see the summaries from HuffPost’s Jason Linkinsand Jeffrey Young.)
Republicans’ history of promising and then not delivering comprehensive health care legislation — a history, after all, that goes back decades — hints at a deep, fundamental disagreement with the entire idea. Republicans will talk up the importance of helping people with pre-existing conditions or providing financial assistance to people for whom insurance is too expensive. But creating a truly universal coverage system — in which everybody has access, regardless of income or health — requires taking steps that many conservatives simply can’t abide.
Specifically, universal coverage requires some combination of regulation, taxes and redistribution (from healthy to sick, and from rich to poor) that Republicans tend to find economically destructive, morally noxious or both. That’s true of wholly nationalized, single-payer systems like you find in France or Taiwan. It’s true of universal schemes of regulated private insurance, like they have in the Netherlands, Singapore and Switzerland. It’s even true of programs in the U.S. that have existed for a long time — not just Medicare but also, to some extent, employer-sponsored insurance.
But rather than admit that they cannot come up with a comprehensive health care plan that will actually work, they engage in a sort of legislation theater in which they toss out talking points about Health Savings Accounts (which only work for relatively healthy people with lots of disposable income who need tax shelters) or propose providing subsidies in exchange for killing the mandate (which would cause private insurance companies to pull out of the exchanges). Some of them are still talking about high-risk pools, which have been tried and which consume tax dollars the way a black hole obliterates matter.
But at the state level, some officials are beginning to panic.
Tonight the Wall Street Journal has a fascinating look something we may soon hear a lot more about in a very rushed and chaotic fashion. Last month, an outfit called the Milbank Memorial Fund (as best I can tell a relatively non-ideological foundation focused on health care policy) held a secret one day meeting in Chicago for officials from states who may suddenly find their citizens cut off from Obamacare health care insurance subsidies because of the new GOP challenge to the law.
The verdict. Basically that they’re screwed.
This doesn’t necessarily mean that the Republican legislators in those states are likely to do a damn thing, even if there were a damn thing they could do. However, there’s talk that some state governors might find some work-around that would allow the subsidies to continue, like declare that their exchange is a state exchange, dammit, even if the federal government created it. Maybe they could set up some shell site interface to the federal exchange and call it a state exchange. Whatever.
All I can say right now is that I’m glad I live in New York, which has its own exchange.