Last week, House Republicans engaged in a bit of fancy word-play to obscure the fact that millions of people are going to lose their health insurance once they start hacking away at the Affordable Care Act (ACA). Republican aides said to the New York Times: “Our goal here is to make sure that everybody can buy coverage or find coverage if they choose to.” In other words, they want to guarantee a “right to purchase” without a guarantee that coverage actually will be affordable. And even those who can find affordable premiums are likely to find much bigger holes in their coverage than exist today.

Republican leaders seem to hope they will be able to insulate themselves against political backlash with a combination of rhetorical obfuscation plus a delay between when they administer the poison and when health insurance markets keel over. But it’s not likely to work for a lot of reasons.

First, the repeal and delay strategy will not stop the individual insurance market from beginning to unravel quickly.

Second, people generally get really upset when someone tries to take away their benefits.

Third, the argument that the ACA was unraveling anyway does not hold water, with demand for coverage on remaining strong.

In any event, the claim will not shield the majority party from their failure to act to make things better. Although some of the effects of repeal will take time to become apparent, Republicans now control the White House and both houses of Congress, and the chances of that changing before 2020 are very slim. There simply isn’t anyone else plausible to blame.

And the more time goes by, the worse things will get. It’s not only the 22 million people who have gained coverage from Medicaid expansion and tax credits who are at risk. Since repeal and delay will crater the whole individual insurance market, an estimated 30 million people are likely to lose coverage But that’s not all. Thanks to the ACA, protections against pre-existing condition exclusions extend across all insurance markets. Last week, the Kaiser Family Foundation released an analysis that found 52 million people would be uninsurable without the ACA. Many of them have employer-sponsored coverage, but without the ACA they are still vulnerable to a change in circumstances.

A Mystery Solved?

Maybe tax policy holds the answer to the question I posed a couple of weeks of why opposition from essentially the whole health care industry doesn’t seem to be enough to divert Republicans from the rash course of repealing the ACA without having a replacement ready. This week we saw two major reports, one from Families USA and one from the Tax Policy Center that quantify the tax consequences of “repeal now, replace later, maybe”. The bottom line — low- and moderate-income people are losers, but there is a big windfall for the wealthy. How big and how wealthy? The top 1/10th of 1 percent of households would get a tax cut averaging $197,000. In these times of great uncertainty it is nice to know that tax cuts for the rich are an all-purpose policy remedy that never goes out of style.

Taking our eyes off the ball

A recent blog from Gallup discusses inefficiency in the U.S. healthcare system. Usually I am wary of arguments that start by complaining about the percentage of GDP that goes to healthcare – they often wind up as arguments for why we have to take benefits away from seniors, people with disabilities and low-income kids. But in this case, the author zeroes in on some very real problems that drive up U.S. health spending without delivering additional value for patients–specifically excessive administrative costs and monopoly pricing. Tackling these problems would be a productive way to reduce the cost of health insurance. Unfortunately, we seem to be on a different path, one that involves the return of experience rating (at least indirectly), discriminatory benefit design and increased cost-sharing.

Believe it

Some people don’t want to believe that President Trump will go after Medicare. After all, didn’t he promise not to during the campaign?

But watch what he does, not what he says. Tom Price, his choice for HHS Secretary, supports Medicaid block grants, Medicare vouchers and balance billing. Now he is nominating another appointment who holds extremist positions on health care – Congressman Mulvaney, a Tea Party favorite who has “strong appetite” for cutting Medicare. It’s hard to take that as a good omen.