New Year's was a new day, too, for that abused two-and-a-half-year-old ragamuffin known familiarly as Obamacare, the milestone marking the end of any chance of its demise.
With some nine million Americans now enjoying the new protection of health insurance guaranteed by the U.S. government and millions more assured by the end of the first enrollment period this spring, Republican leaders acknowledged that it had passed the point of no return. Like Social Security, disability insurance, Medicare and other rights conferred by the government, Obamacare reached the point that too many people who are not extremely poor are beneficiaries to go back.
A Republican majority in Congress and president, both possibilities in 2017, may repeal the Patient Protection and Affordable Care Act but in name only. Three more enrollment periods by the spring of 2017 will have left only a relative handful of people uninsured, and only the flintiest congressman would vote to lift their protections.
Republicans are beginning to craft reforms to replace the Affordable Care Act, but they largely keep and in some cases build upon the central features of the law or else are calculated to dismantle it subtly over time, as they hope to do with Medicare and Social Security with a voucher or privatization scheme.
Obamacare's critics from the other side — those who want a single-payer system in which the government provides both the guaranty and the insurance itself — are not so sanguine as the Republicans. They hope disgust with the profiteering of the insurance industry will produce a revolt and the enactment of the single-payer system envisioned by President Harry Truman, Medicare for all.
Michael Moore, the maverick filmmaker, wrote an op-ed article last week in The New York Times in which he maintained that Obamacare was still "awful" as he had always said but that it was doing so much good that it could not be scrapped. Instead, he hoped that a reinvigorated Democratic Congress would end the profiteering by the insurance and medical industries by installing a "public option" to compete with private insurance plans in the exchanges run by the states or the federal government.
The public option was a feature of the health insurance bill passed by the House of Representatives in 2009, a bill superior in several ways to the Senate version, which eventually became law because the special Massachusetts Senate election left the Senate without the supermajority needed to pass anything else.
But the same political dynamics of the status quo, which made it impossible to enact a single-payer system and make it improbable for Obamacare to be scrapped, make it equally impossible to take away the private industry's monopoly.
A piece in The New York Times outlined the Republican strategy on Obamacare from Jan. 1 forward. This year, as Sen. Lindsey Graham of South Carolina explained it, everyone will continue to blast away at the failures of Obamacare as the chief weapon for the 2014 congressional elections but begin to develop reforms that would replace the law with something they could claim would be better.
It is the strategy they hope will defeat Sen. Mark Pryor and a couple of other Southern senators and give Republicans control of the Senate in 2015. Pryor and the others at risk have a more forlorn hope: that the benefits of the Affordable Care Act will sink in, the alarms built by three years of broadsides will subside, and he will be recognized for having done the decent thing by voting for it. Some 150,000 Arkansans who didn't have it in 2010 by November will enjoy medical insurance, although many may not acknowledge how they got it.
Most people's insurance premiums will not be rising, or at least not at the rate of previous years, as they have been told repeatedly they would. Health care costs have been relatively flat since work on Obamacare began and new cost-saving initiatives undertaken in Arkansas and other states under the new law are flattening or even reducing health spending. People still see their doctor and take his advice, and Grandma gets even more treatment under Medicare rather than having it withdrawn as Republicans had threatened.
But the Republicans seem to have a surer political strategy than Pryor or the Democrats.
Sen. Ron Johnson of Wisconsin, a tea-party hero, acknowledged that nothing could be done now to scrap the law, although he filed suit last week to block his own coverage under Obamacare. "There's something there now," he said. "We have to recognize that reality. We have to deal with the people that are covered under Obamacare." Graham acknowledged that the Republicans must offer something better, not just a return to the terrible past.
A conservative Republican congressman from Georgia, a doctor, is promoting his bill to repeal Obamacare but keep many of its provisions in some form, like requiring insurance companies to insure people with pre-existing conditions, barring them from cutting off insurance to the chronically sick, providing insurance pools for small businesses and giving tax credits up to $5,799 to help people buy insurance.
Rep. Paul Ryan, the 2012 GOP vice presidential candidate, will introduce his Obamacare substitute, which would tax people's employer-based health benefits and, much like Obamacare, use the money to provide tax credits for people to buy insurance. Like Obamacare, it would bar insurance companies from cutting off the sick and fix benefits that every policy must provide.
Another GOP plan in the works would repeal Obamacare's mandate for people to buy insurance and instead enroll everyone automatically unless they directly instructed the government not to insure them.
Obamacare Lite, in other words.
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