The Dog Catches the Car

The dog chases the car, but what will the dog do if the dog catches the car? That’s the joke. The dog has no idea. The dog has a tiny brain. The dog simply chases the car, because it’s great fun. It’s a thrill to feel powerful and threatening – assuming dogs have egos. Dogs, however, cannot reason out consequences. That requires a bit of abstract thought, beyond the punishment and reward dynamic involved in house training. Humans do complex what-if thinking. Dogs don’t.

Republicans don’t do complex what-if thinking either. For eight years Obama was wrong about everything. If he proposed it, they opposed it, even if they thought of it first, like the “individual mandate” that would force everyone to buy health insurance. That would create a massive pool of people, most of whom were pretty healthy, paying in, to cover the massive costs incurred by the unlucky few. There would be no freeloaders. Freeloaders are despicable, and that mandate would keep things solvent. The Heritage Foundation came up with that, but when that became the key element that would make Obamacare work, that was the one thing that Republicans fought tooth and nail. That was what they took to the Supreme Court, and lost. Antonin Scalia fumed – this was like the government telling everyone that they had to eat broccoli – the metaphor at the time, thanks to Fox News. Scalia lost that argument. The “individual mandate” wasn’t broccoli. It was just a tax. Congress can raise taxes, for the common good. That seemed to be the case here. Obamacare was constitutional. It stood.

Republicans fumed, and then the Republican House passed about fifty bills repealing Obamacare, all of which died in the Senate. The Republicans didn’t have the necessary sixty votes over there to stop debate and bring even one of those repeal bills to the floor for an up-and-down vote, which wouldn’t have mattered anyway. Obama would have vetoed any repeal that finally made it through the Senate. They certainly didn’t have the votes to override a veto – but it’s a thrill to feel powerful and threatening, and it’s best not to catch the car. They never had an alternative to Obamacare. They didn’t even try. Fixing the healthcare system is hard. They’d come up with something better when they caught the car. Until then, they’d bark, loudly.

That became habitual, and it wasn’t just Obamacare. It was the Iran deal that actually took care of a serious problem for at least ten years. It was the Paris Accords that most nations agreed to in a worldwide effort to slow climate change. That’s real. The science is indisputable – but science must be bunk, and everyone else must be wrong. Obama’s opening to Cuba was bunk too, but Republicans couldn’t argue that fifty years of sanctions and a total embargo had accomplished anything at all. They barked anyway. It’s a thrill to feel powerful and threatening. The nation yawned. Tourists booked flights to Cuba.

The Republicans also knew that Hillary Clinton would win the presidency. All the polls showed that, so Donald Trump would be just fine as their candidate. He was powerful. He was threatening. And he would lose. They could keep barking and feel good.

And then he won. They caught the car. Hillary Clinton got more than two and a half million more votes, but they caught the car.

Garrison Keillor is a bit bitter about that:

A minority of the electorate goes for the loosest and least knowledgeable candidate, certain that he will lose and their votes will be only harmless protest, a middle finger to Washington, and then – whoa. The joke comes true. You put a whoopee-cushion on your father’s chair and he sits down and it barks and he has a massive coronary. You wanted to get a rise out of him and instead he falls down dead. Very funny.

Thank you, Michigan, Wisconsin and Pennsylvania for this wonderful joke. Voters in high dudgeon against Wall Street manipulators and the Washington aristocracy vote for the billionaire populist who puts tycoons in power and the Republican hierarchy who owned the logjam that the voters voted against.

They’ve done it now:

He is a showman, and oddity has paid off for him, as it did for Lady Gaga and Gorgeous George and Liberace. But the public demands new tricks. Today, railing at the journalists who slavishly cover him is, like bear-baiting or lion-taming, entertainment enough, but by next fall he will need to pull canaries out of his ears, and by 2018 he’ll be diving on horseback from a high tower into a pool of water while playing “Malagueña” on a trumpet.

That may be only a slight exaggeration. No one was more surprised at Donald Trump winning than Donald Trump. The transition is not going well. He caught the car and has no idea what to do with it, although he’s been putting on a brave face, even if no one knows what he stands for now. What he was against he’s kind of for now. What he was for, like torture or maybe something worse, because “they” deserve it, he’s kind of against now. He said he’d never touch Medicare, but now he seems okay with Paul Ryan’s plan to phase that out in eighteen months. This is painful to watch. What have we done?

And then there’s Obamacare. It must go. They said so, but they never did the complex what-if thinking about that, and now they’re in a bit of a fix. Margot Sanger-Katz explains that:

Just a few weeks ago, Donald J. Trump and Republicans in Congress were talking about how Obamacare’s insurance markets were floundering, and how insurance companies were fleeing while prices were spiraling out of control.

The failure of those markets, they argued, was the reason Obamacare should be repealed.

Now, Republican leaders are considering a legislative effort to roll back major provisions of the health law, but the plan they’re considering would keep the current system in place for at least two and possibly three more years.

They simply never expected this:

The nickname for the plan is repeal and delay, and the assumption underlying it is that the current system will be sustainable for as long as it takes Congress to pass and the White House to install a new health plan.

The plan might be better described as “zombification.” It is not at all clear that Republicans can easily time the expiration date of the Obamacare markets. Insurance experts say the resulting zombie market – not dead, but not alive either – would suffer from many of the maladies of the existing system, and quite a few more. The result on the books might look like the status quo, but millions of Americans could lose their insurance and others could pay much higher prices to keep their coverage.

Perhaps they should have looked into what Obamacare actually is:

Obamacare was devised as a market system rather than a government program like Medicare. Private insurers compete to offer health plans to customers who don’t get insurance from their jobs or the government. It sets up rules and establishes federal subsidies to help encourage people to buy insurance. But it relies on the voluntary participation of insurance companies to function.

There’s nothing in the health law that forces insurance companies to sell insurance if they don’t want to – as we learned this year, when several major carriers exited the market. And there’s good reason to think that, with the death of Obamacare looming, many more companies would rethink their decision to sell Obamacare policies in the zombie interval.

That’s the free market at work, but free markets can be a bitch:

In an interview with The Milwaukee Journal Sentinel this week, Speaker Paul Ryan promised that the transition would ensure that “no one is worse off.” That promise could be as hard to keep as President Obama’s statement that, under Obamacare, “if you like your health plan, you can keep it.”

Well, the problem really is structural:

Even the law’s defenders acknowledged that the markets were rickety and vulnerable. President Obama, in an article published in The Journal of the American Medical Association this summer, suggested major policy changes to backstop the markets. Hillary Clinton’s campaign included a laundry list of new programs meant to address Obamacare’s recent troubles.

Those changes, which would have involved extensive new spending on the existing system and the entrance of a government-run backup insurer, sometimes called the public option, are now off the table.

More modest fixes might have a better chance of passing. As The Hill reported last week, some Republicans in Congress are discussing a package of smaller short-term changes that would make the Obamacare markets more appealing to insurance companies during the zombie period.

Christopher Condeluci, who was a GOP finance committee council when Obamacare passed and now runs a policy consulting business, said he had spoken with current staffers considering such options. Over the last few years, Republicans have resisted changes that would make Obamacare work better, but Mr. Condeluci said that the election had shifted the outlook.

“If there’s disruption, even in a wait for repeal and replace, Republicans are going to look terrible,” he said. “And the Democrats are going to rightly blame them.”

That’s because things will fall apart:

For insurers that are losing money now as the market finds its legs and that are well-established in other lines of business, there is less incentive to stick around. The motivation for health plans, particularly large, national for-profit companies, had always been that Obamacare was a long-term growth opportunity, worth some headaches and losses early on. With the program’s end in sight, that hope would be gone, and insurers might balk at the effort required to change products and comply with new, more generous rules.

Marilyn Tavenner, the president of America’s Health Insurance Plans, a large insurer trade group, told my colleague Reed Abelson this week that the current law “needed to be improved.” Her group has not come out against a repeal and delay plan, but it has not guaranteed that insurers would stay put if one passed.

Things will probably stay stable through the end of next year. Insurance companies have signed contracts to offer health plans, and people have already signed up for them.

After that, the future may be less certain than the GOP plan’s nickname suggests. Exits might not happen everywhere, but just as the Obama administration has struggled to keep reluctant insurers in the market, there would be little the Trump administration could do to prevent further insurer flight.

Get rid of Obamacare. There’s nothing. That’s that. All alternatives fail, although the health insurance industry is outlining what it wants to keep when Republicans repeal Obamacare:

The insurers, some who have already started leaving the marketplaces because they are losing money there, say they need a clear commitment from the Trump administration and congressional leaders that the government will continue offsetting some costs for low-income people. They also want to keep in place rules that encourage young and healthy people to sign up, which the insurers say are crucial to a stable market for individual buyers…

Marilyn Tavenner acknowledged that the current law “needed to be improved.” But she emphasized that there was widespread agreement among Republicans about the need for some the law’s provisions, including covering people with expensive medical conditions. President-elect Donald J. Trump has also signaled his support of this popular provision. “There are common starting platforms,” she said…

Ms. Tavenner said the industry wanted to know more about what the Republicans were planning, including information on the fate of the Medicaid expansion under the law. “We still have more questions than answers,” she said. “We don’t want to disrupt individuals who are relying on our coverage,” she said.

Kevin Drum wonders about these demands:

Here’s the case for laughing: the insurance industry says it’s OK with repealing Obamacare, but we should maintain the pre-existing conditions ban, the individual mandate, the subsidies for low-income families, and the Medicaid expansion. Needless to say, that is Obamacare.

Here’s the case for crying: “The market has already been a little wobbly this year,” Tavenner said. If it looks like any of these four provisions are going to be repealed with nothing to replace them, insurers will simply pull out of the market at the “next logical opportunity.” That would be about six months from now…

There’s a good chance this doesn’t just mean pulling out of the Obamacare exchanges. If the mandate and the subsidies go away, but the pre-existing conditions ban stays in place, insurers might very well pull out of the individual market entirely. Republicans are playing with fire here, and it’s not clear if they even know it.

Josh Marshall quantifies that:

Depending on how they go about it, we are talking about tens of millions of Americans who are about to lose their health insurance coverage. Some people might think that’s a big deal. For the moment the main policy debate within the GOP is how to accomplish this and evade as much blame as possible…

The total number set to lose their coverage is a bit over 23 million Americans (23,134,000). Of those, 12,311,000 lose their Medicaid expansion-based coverage; 8,963,000 are exchange purchasers who benefit from significant federal subsidies; 1,390,000 are young adults under the age of 26 who are allowed to remain on their parents plans; a final 470,000 are basic health care plan enrollees in Minnesota and New York…

And here’s something even more interesting, partial repeal turns out to be worse than full repeal. The Urban Institute has a new study showing something that seems paradoxical, but actually makes sense if you know the way the health insurance industry has integrated with and remade itself to operate with the ACA. Urban Institute’s numbers of people who lose insurance is slightly lower… but if repeal is partial, they project an additional 7.3 million would lose their coverage. That brings the total to 29.8 million, close to 10 percent of the people in the entire country.

It seems that the Heritage Foundation was right all along:

Why would partial repeal hurt more people than full repeal? Well, in this case partial repeal means repealing the money (the incentives) without the regulatory structure. In the words of the Urban Institute study “the additional 7.3 million people become uninsured because of the near collapse of the non-group insurance market.” Basically you’re leaving the regulations intact but removing the money that makes them possible. So everything goes haywire and you get a lot of collateral damage. Why would you do that? Simple. The rules of the Senate allow you to do that with 50 votes. It’s politically easier to destroy care for an additional 7 million people.

One more thing to consider as these people are losing their health insurance – a bit part of the equation that very few people are talking about is that repealing the money part of the bill is a massive tax cut for the wealthy. That’s the part that Ryan wants to get his hands on first. That’s the real prize.

Yes, Obamacare included a small jump in taxes for those earning over two hundred grand a year, and a much larger increase on investment income – and those folks want their money back. Paul Ryan will give it back to them, but at a cost:

The nation’s hospital industry warned President-elect Donald Trump and congressional leaders on Tuesday that repealing the Affordable Care Act could cost hospitals $165 billion by the middle of the next decade and trigger “an unprecedented public health crisis.”

The two main trade groups for U.S. hospitals dispatched a letter to the incoming president and Capitol Hill’s top four leaders, saying that the government should help hospitals avoid massive financial losses if the law is rescinded in a way that causes a surge of uninsured patients.

Yes, hospitals will close, particularly those in rural areas and in big cities that have any kind of underclass, as all big cities do, so this might be necessary:

The hospital groups say that if Trump and Congress repeal the Affordable Care Act without replacing it right away, they should also restore government payments for hospital care of Medicare and Medicaid patients to what they were before the 2010 law. When it was enacted, the premise was that hospitals could absorb lower payments if more people were insured.

The Republicans didn’t think of that. Like the dog chasing the car, they were incapable of complex what-if thinking. After eight years, they were out of the habit, but that might be just too bad, as Greg Sargent reports this:

The emerging GOP plan to repeal Obamacare on a delayed schedule – and then maybe kinda sorta replace it later – has raised a big question: Will Democrats help Republicans pass a replacement that is far less generous and comprehensive than the health law is, allowing Republicans an escape from the political fallout from repeal?

In an interview with me, Senate minority leader Chuck Schumer answered this question with a resounding no. Under no circumstances, he vowed, would Democrats throw Republicans such a political lifeline.

“We’re not going to do a replacement,” Schumer said of the Senate Democratic caucus. “If they repeal without a replacement, they will own it. Democrats will not then step up to the plate and come up with a half-baked solution that we will partially own. It’s all theirs.”

That may seem petulant – sore loser stuff – but it may save the day:

Whenever repeal does kick in, Republicans have insisted, they will have some kind of replacement ready. And here’s where Democrats come in. Republicans appear to be calculating that the looming prospect of millions losing insurance will force Dems to cooperate with them to pass a replacement that covers far fewer people and offers less in consumer protection than the ACA does. (They may need Dems to pass a replacement, because some conservatives may not vote for anything that spends and regulates to expand coverage.) But if Democrats do hold the line against anything far short of the ACA, they may be able to leverage Republicans into replacing it with something that is not nearly as regressive as the GOP replacement might otherwise have been.

This is what Schumer is now vowing to do. Asked directly if Democrats would refuse to support anything that falls significantly short of the ACA – in terms of expanding social welfare – Schumer said: “The odds, after they repeal without any replacement, of us sitting at the table to do something that will chop one arm off instead of two is very small.”

“They’re giving us tremendous leverage,” Schumer insisted.

That’s another thing the Republicans didn’t expect when, to their surprise, they actually won the presidency, along with the House and Senate. The yapping little dog actually caught they car, and now they have to drive the car, and dogs can’t drive. They won’t get what they want – but then they never knew what they wanted. Dogs have tiny brains.