This new American president-elect, among other idiosyncrasies, speaks with casual grandiosity. He promises really big things as if they’re really easy to do.
A good example is Donald Trump’s declaration that he’ll repeal and replace Obamacare, which would be a grandiose thing, and “do it very, very quickly,” as if there’s nothing to it.
About 22 million people are newly insured for health care under the Affordable Care Act. It is not a casual matter to tell that many people that the health insurance you extended to them three years before will now simply be taken away.
It’s complicated. The Congressional Budget Office says simply ending Obamacare would cost the federal treasury more than $130 billion, and perhaps more than $350 billion, over a decade.
That’s because there are taxes and fees in Obamacare that produce income that would be lost. And it’s because there are Medicare cuts to providers in the ACA, offered on the trade-off that hospitals would get the money back from newly insured patients paying their bills with Medicaid expansion.
It’s also because having 22 million people suddenly walking around uninsured runs the risk of costing the rest of us more than subsidizing their health-insurance premiums.
Simply passing a bill to repeal Obamacare is so easy that the U.S. House of Representatives has done it pretty much weekly, whenever a member of the Republican caucus needed a political booster shot. But what always made the ritual easy, and hollow, was that it was reliably pointless, considering that the Senate was certain to leave the bill languishing in a Democratic filibuster every time.
Then, last year, the two chambers decided to use the budget reconciliation process, by which money could be excised by a simple majority vote that couldn’t be filibustered. But that also was easy, for two reasons.
One was that everyone knew President Barack Obama would veto the bill. The other was that the bill called for ending the Medicaid-expansion part of Obamacare not right away, but after two years, during which the Republicans in Congress would figure out how to replace it.
In January, the Republican Congress will enjoy a Republican president who would not exercise a veto if they rammed through Obamacare repeal by the budget reconciliation process and deferred the actual effective date for, say, two years.
Back in Arkansas, Republican Gov. Asa Hutchinson was explaining to reporters last week how that presumably would work.
He assured that the state’s relatively popular private-option form of Medicaid expansion would be fine for the time being. Beyond that, he indicated he would ask pretty much right away that this friendly new Republican president grant the state waivers on Medicaid expansion that the Obama administration rejected.
One waiver would be not to send Medicaid money open-endedly as legitimate expenditures arise, as happens now, but as a finite “block grant.” The other waiver would be to give the state flexibility to operate as it chooses within that finite block grant, perhaps applying an assets test and a work-training requirement.
Until now, the federal government has eschewed an assets test on the premise that Medicaid exists to assist people lacking in disposable income, but not to hold against them the lifetime-earned ownership of a house or a car or a stock. And, until now, the federal government has insisted that Medicaid is a health program for the needy, not contingent on referral to a jobs program. It didn’t want to tell a guy in a wheelchair to get up and load some crates if he wanted to see a doctor.
In the longer term, probably two years, Hutchinson said the state would work with this friendly new national administration on how to replace the full essence of Obamacare.
Perhaps states could get separate block grants for subsidies to lower-income, non-Medicaid customers on the health-care exchange.
The idea of a block grant with state flexibility is to control and make known the federal government’s outgo while empowering states to make their own rules to stay within their grant amount. It’s not horrible as a concept except when states spend up their block grant and human needs continue to arise, or when mean-spirited governors and legislatures make eligibility unfairly restrictive.
Not negotiable to Hutchinson, nor to Republicans generally, is their philosophical opposition to the underlying mandates of Obamacare — on individuals to get health insurance and on employers of a certain size to assist employees with it.
But Hutchinson and practically all Republicans want to keep the Obamacare provision saying insurance companies can’t turn someone down simply because of a pre-existing condition.
The problem is that health-insurance carriers say they can’t compile a pool adequate to cover all pre-existing conditions unless everyone — young and old, well and sick — is made to ante up.
It sounds like a conundrum. But fear not. Our incoming president does grandiose things with casual effortlessness. Or at least he says he does.
John Brummett, whose column appears regularly in the Arkansas Democrat-Gazette, was inducted into the Arkansas Writers’ Hall of Fame in 2014. Email him at [email protected]. Read his @johnbrummett Twitter feed.