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Bitter Pill

Will the cure for the Affordable Care Act make matters worse?

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'This bill is being shoved down the throats of the American public" was a well-traveled Republican refrain around the Affordable Care Act as it wended its way through the legislative process back in 2009, and a favorite rhetorical talking point of former House Speaker John Boehner.

Now the Republican majority promises to repeal Obamacare as the first order of business for the 115th Congress. And it appears that they aren’t proposing any sort of replacement for it, a move that will likely cause pain in California and across the country.

The Republican plan is to “repeal and delay,” but nobody knows if a GOP omnibus health bill is in the offing that would replace some of the popular aspects of Obamacare, which include a ban on denying coverage based on pre-existing conditions and a ban on annual caps on coverage.

"What we don't know yet is, when will it take effect?" says U.S. Rep. Jared Huffman. "Will there be a two-year cliff or a four-year cliff?"

The GOP plan also includes a promise of extortion if Democrats don’t go along. House majority leader Kevin McCarthy says that if Democrats don’t participate in post-Obamacare, then they’re responsible for whatever consequences ensue.

The Sonoma County chapter of Organizing for Action, the post-Obama, activist-outreach organization, has been busy protesting McCarthy’s office and that of fellow California GOP Rep. Darrell Issa, neither of whom support the idea of healthcare as a basic human right, but who represent districts with significant buy-in to the ACA.

“When they know that their district is going to push back on them, it might give them pause,” says Sonoma-based OFA organizer Linda Hemenway. “We’re trying to educate the public about what’s going on, and our basic premise is that you can’t repeal it without a replacement that has been presented to Congress and explained to the American public, instead of this fantasy replacement that the American public supposedly supports. We’re on the defensive, we’re under attack and we’re going to say, ‘Do you really want these rights and benefits taken away from you?’”

Obamacare has generally been a benefit to California and to the North Bay. The state embraced the Medicaid expansion that went along with the healthcare overhaul, and was one of the first states out of the gate to set up a state-run exchange, Covered California. Thanks to Obamacare, the state halved its uninsured population, and the reforms have trickled down to hospitals, which are seeing fewer people in their emergency rooms—amid a greater, holistic appreciation for the benefits of preventative care. The Sutter Health system has experienced big savings in its hospitals located throughout California, including one in Sonoma County. The company reported that it spent $52 million in uncompensated “charity care” in 2015, compared to $91 million in 2014.

The North Bay has embraced the Obamacare benefits and mandates, and stands to lose if the ACA is repealed. The Sonoma County Economic Development Board published a report in 2016 that highlighted benefits brought to Sonoma County citizens under the law, especially given the county’s aging population and composition of its labor force. Many lower-income immigrants qualified for the Medi-Cal expansion.

"Healthcare is contributing to the economy's vitality," the report noted.

The potential post-ACA risk for a place like California, which enthusiastically embraced Obamacare and a Medicaid expansion, is that it has the most to lose under a Republican repeal-and-delay plan.

The Urban Institute estimates that up to 30 million Americans will lose insurance if the Affordable Care Act is repealed, and even if the Republican Party decides that the politics are against them and starts cherry-picking popular aspects of the law, it’s unclear how they’ll keep the ban on denying coverage based on pre-existing conditions without, as Huffman says, “wading into risk pools and market forces.”

Previous GOP repeal bills haven’t addressed those issues. The Republican position on Obamacare has also helped to drive down enthusiasm among younger people to sign up, a key piece of the bill’s success in driving down the cost curve over time.

The previous GOP push to undo Obamacare has been pretty simple: repeal it and send the bill to Obama who dutifully vetoes it. Now that the GOP has total power to eliminate it without a replacement, there are signs that there are limits to “shove it down your throat” politics. Even as the Republicans vow to disable the law, Americans continue to flock to the ACA-created health exchanges to buy an insurance product suitable to their budget. “Will [Republicans] be smarter,” says Huffman, “or just set up some distant cliff and count on everyone to come together before the cliff takes effect? We’ll see.”

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