As we await the verdict of nine Supreme Court Justices on the constitutionality of all or part of the Affordable Care Act (ACA), it is worth asking what the remaining Republican Presidential nominees would create in its place. We know that they would have to create something, because each is committed to the rapid abolition of what they insist on calling “Obamacare”. Mitt Romney’s Plan for Jobs and Economic Growth is quite clear: “An Order to Pave the Way to End Obamacare,” it tells us, will be the first of “five executive orders for Day One” of a Romney presidency.[1] Newt Gingrich would be similarly engaged on the first day of his presidency. So too would Rick Santorum and Ron Paul. All four remaining Republican presidential candidates are enthusiastic First Day Abolitionists!

            But what we don’t know in any detail is what exactly would follow on Day 2, if any of them were elected in November. We know some things, but we do not know anywhere near enough.

·         We know that Mitt Romney would “direct the Secretary of Health and Human Services and all relevant officials to return the maximum possible authority to the states to innovate and design health care solutions that work best for them.” We know that he has changed his position from “pro-choice” to “pro-life”;[2] and that he now supports the Blunt proposal allowing employers and insurers to limit coverage of contraceptives if they have religious/moral objections to that provision. We also know he is proposing to return Medicaid spending entirely to the states, that he would raise the Medicare eligibility age by one month per year during his presidency, and that he would offer Medicare recipients (by 2022) a choice between “the traditional, fee-for-service government health-care program and a new option to purchase private insurance, with the cost partly supported by the government.”[3] Since so many of those proposals also appear in the 2012 Ryan budget passed by the House in March, we also know that Romney has declared that budget “a bold and exciting effort, very much consistent with what I put out earlier.”[4]

·         We know that Rick Santorum – ultra-conservative as he is on abortion, gay marriage and even contraception – would, as his website has it, “repeal and replace Obamacare with market based health care innovation and competition to improve America and America’s health and create jobs.”[5] We know too that he would work with Congress, as he told the Wall Street Journal, “to replace Obamacare with competitive insurance choices to improve quality and limit the costs of health care, while protecting those with uninsurable health conditions.”[6] We also know that Rick Santorum dismisses Romney’s health care proposals as eleventh hour conversions from his (Romney’s) own equivalent to the ACA. ‘The bottom line,” as he told Romney during the February 22 debate in Arizona, is “you used federal dollars to fund the government takeover of health care in Massachusetts, and then Barack Obama used it as a model for taking over his health care system in America.”[7]

·         We have some insight into Ron Paul’s thinking on these matters from the candidates’ debate in September when Wolf Blitzer asked him what we should do if someone who had chosen not to take out health insurance suddenly needed long-term care. “That’s what freedom is about, taking your own risks,” was Paul’s reply. The audience went even further. To Blitzer’s follow up question – “Society should just let him die?” – they broke into cheers and shouts of “Yeah!”[8]

·         And we know that late conversions to conservative positions are not a Mitt Romney monopoly. As recently as 2007 Newt Gingrich was proposing that “Congress should require anyone who earns more than $50,000 to purchase health insurance or post a bond;”[9]  and in 2011 Gingrich criticized the Ryan proposals that were later endorsed by Mitt Romney as too radical a piece of conservative social engineering.[10] That is not quite the Gingrich we have seen on the campaign trail these many months.

·         Well might Gingrich have criticized Paul Ryan, for in the 2011 budget, House Republicans proposed not simply scrapping the ACA. They also proposed replacing Medicare entirely with a voucher system, one in which seniors would receive federal money to help buy private insurance but also one in which any top-up costs would be borne by seniors themselves. In 2012 Ryan and the House Republicans modified that proposal slightly, allowing future Medicare recipients to choose between staying in the program or receiving limited help to buy private health insurance. For in 2012, Ryan’s main target was not Medicare but Medicaid – with the new budget proposing immediately to scrap the extensions of coverage mandated by the ACA, and to restrict the federal role in Medicaid thereafter to the writing for each state of a single check (indexed for inflation and population growth) which state officials could spend on the medical needs of the poor as they saw fit. The Ryan 2012 budget also proposed reducing the total growth in the amount of those Medicaid checks by $810 billion over the next decade – in effect cutting total federal spending on the medical needs of the poor by 20%.[11]

---

We also know one other set of things – about “Obamacare” itself. Although the Affordable Care Act has already been scaled back in key ways,[12]  we know that certain of its provisions have already brought significant change to the U.S. health system, and that its remaining provisions promise even more significant changes to come.[13] So it is legitimate to ask whether Republicans in Congress and on the presidential stump are proposing to roll back any/all of the following ACA-initiated changes?

·         CONSUMER RIGHTS Under the ACA, insurance companies are no longer allowed to exclude potential customers on the basis of pre-existing conditions. Nor are they allowed to alter premiums if their customers become sick, or to set lifetime/annual limits on payments for care. (This in the context of an American population in which, in 2007, as many as 36% of those seeking private health insurance were denied such coverage or charged higher premiums for just those reasons,[14] and in which more than 7 Americans in 10 currently support the retention of this provision.[15])

·         INSURANCE FOR YOUNG ADULTS Parents are now able to keep their children covered on their health insurance until the children are aged 26. The EPI estimate that 490,000 young adults gained coverage between 2009 and 2010 because of this provision in the ACA, a twelve month period in which employer-sponsored health insurance fell for all other age groups in the U.S. population.[16] (This in the context of unemployment rates among 18—24 year olds currently running at over 20%, one in which at least 15 million 19-29 year olds lacked health insurance in 2009, [17]and one in five Americans aged 25-34 are reportedly now living back with their parents.[18])

·         HEALTH-INSURANCE EXCHANGES From 2014, Americans unable to negotiate employer-provided health insurance cover will have access to state-level insurance exchanges in which they will be able to obtain private health insurance, with federal assistance if their income is too small. 30-34 million Americans are expected to gain coverage under this and other provisions of the ACA. (This in the context of a steady diminution in the percentage of the U.S. labor force with access to employer-provided health insurance – down to 58.6% in 2010, when it had been 69.2% in 2000[19] – and a continuing rise in the number of Americans without health insurance – up by one million in 2010 to just under 50 million.[20] Nine million working-age Americans lost their jobs, and with it their health coverage, between 2008 and 2010.[21])

·         FINANCIAL HELP WITH INSURANCE PREMIUMS Americans earning up to four times the poverty level for their size of family will have access to federal funds to help pay for health care coverage. (This in the context of a distribution of income in the contemporary United States that keeps one American in three living within one tranche of the poverty level, and in which the cost of health insurance has far outstripped the rate of wage increase in the last decade –  health costs having more than doubled as wages have stagnated.)

·         EXPANSION OF MEDICAID Americans living below the poverty line – and indeed those living up to 133% above it – will now be eligible for Medicaid, regardless of whether they do or do not have children. (This in the context of a poverty rate among all Americans of 15.1 percent, among African-Americans of 27.4 percent and among Hispanic Americans of 26.6%.[22])

·         WOMEN’S HEALTH Women now enjoy increased access to preventive care services without copays and deductibles.  By 2014 insurance companies and Medicare will be obliged to provide a wide range of these services, including access to a full range of FDA-approved contraceptives, without any gender-rating of insurance premiums. “About 54 million Americans now have expanded coverage of at least one preventive service as a result.”[23] (This in the context in which 98% of Catholic American women regularly use some form of birth control, [24]and one in which, before the passing of the ACA, 87% of all individual insurance plans excluded maternity care on the grounds of it being “a pre-existing condition.”[25])

·         AID TO SENIORS Senior citizens on Medicare now have federal help financing part of the doughnut hole in their purchase of prescription drugs. In 2011, 3.6 million senior Americans saved more than $2 million as a result.[26] The Act proposes closing the doughnut hole entirely by 2020. (This in the context of a Medicare population of over 48 million.)

---

So there are questions to which the American electorate deserves clear and unambiguous answers from the men who would take the White House back for the Republicans in November.

1.      At the very least, we deserve to know if “the abolishing of Obamacare on Day 1,” to which they are all committed, will involve the abolition of some/all of the detailed – and popular – changes already implemented or underway. Are the Republican candidates proposing to do away with the ban on pre-conditions? (Santorum, at least, is on record as saying the ban should go.[27]) Will children under 26 be covered on their parents’ policies?  Will Americans on low income receive federal funding to help purchase health insurance? Will the numbers of the involuntarily uninsured go up or go down if the Republicans win the White House? We need to know.

2.      We also need to know where the candidates stand on the consequences of the Ryan budget. Where do the candidates stand on the CBO’s recent estimate that, when by 2022 Medicare has been replaced by vouchers, senior citizens will find themselves responsible for up to two-thirds of their total medical bills?[28] Do the candidates really support the detail of the Ryan budget when its proposed Medicaid spending limits are anticipated to take between 14 and 28 million poor Americans out of coverage by 2022, and when its associated cuts in food stamps would adversely impact the basic diets of the 47 million Americans now dependent upon them?[29] Is it the policy of the Republican presidential candidates, as it is of the House Republicans supporting this budget, to see federal spending on Medicaid, SCHIP and subsidies for private insurance be 75% lower by 2050 than they will be if existing legislation remains in place?[30] And how do Republicans square their advocacy of privatizing Medicare with their claim that seniors and the poor will not be adversely affected, when there is clear evidence, from the CBO and others, that privatization would “likely result in higher out-of-pocket costs and greater limits to coverage for many Americans.”[31]

3.      And again, how exactly will the Republican proposals achieve better cost-savings than those projected for the Affordable Care Act?[32] Those ACA cost savings, as we know, would have been greater had not Republican legislators blocked the inclusion of a public option in the state-level health exchanges, and had they not also blocked the creation of a single nation-wide exchange. Even now, House Republicans are blocking the creation of the Independent Payment Advisory Board designed explicitly to reduce costs (the CBO had it saving $3 billion between 2018 and 2022.[33]) Unless the new requirements on preconditions and the individual mandate are dropped in any Republican-designed health care reform, how can that reform avoid a veritable explosion in the cost of insurance premiums? (“Insurance premiums would rise by as much as 25 percent if the healthcare law is implemented without an individual mandate, according to a new analysis from the Robert Wood Johnson Foundation.”[34]) Deregulated insurance companies have historically inflated health care costs in the United States,  putting profits before service to leave the U.S. with the most expensive health care system in the advanced industrial world. How exactly will market-based reforms avoid that fate in the future?

4.      We need to know so many other things too. Why is the individual mandate – once the corner-stone of conservative proposals to reform the U.S. health care system – now so unacceptable to conservatives?[35]  Why are they so upset with this dimension of the ACA, when the individual mandate will apply to so few people – maybe 2% of all Americans at most?[36]  Why are conservative legislators so opposed to this example of privatization when they are so keen on other examples – not least the privatization of Social Security – whose constitutional legitimacy will also be brought into question if this key element of the ACA is indeed struck down?[37]  And why seek to replace Medicare with subsidized private insurance when the evidence is abundantly clear that Medicare is significantly cheaper to deliver and administer than any form of “managed competition” yet devised?

5.      And of course we still to know why “Obamacare” was acceptable to Mitt Romney when he was Governor of Massachusetts, but is not acceptable to Mitt Romney when seeking the Republican presidential nomination. Why, when the Massachusetts experiment is actually working so well?[38] It was apparently obvious to Romney the governor that the market in health care and the market in broccoli were not the same – that by not buying broccoli Americans were not adding to the financial burdens of their fellow citizens, but that by not buying health care, they were.[39] So why the change: is this a matter of principle or of politics? If this is simply a matter of politics, what plans does Romney have in place to cope with the chaos which both a full and a partial striking down of the ACA will leave in place in a U.S. health-care system already beginning to implement so many of the ACA reforms? If however it is a matter of principle, then what is the Republican answer to the free-rider problem to which the individual mandate is one possible solution?  Are Accident and Emergency units in American hospitals to turn away those without insurance, or will those with insurance be expected to continue to cross-subsidize those without? We need to know.

---

Political vandalism is always the easier route for parties and individuals when out of office. But with office come responsibilities – and the bigger the office, the greater the responsibilities associated with it. So those Republican politicians who would seek the highest office in the land have a particular obligation to be clear with those of us who would elect them.

·         They need to tell us how a return to market-based insurance reform can hope to clear the way for access to healthcare for all, in an economy as scarred as this one is with income inequality and mass involuntary unemployment?

·         They need to defend and justify their impoverished notion of freedom: freedom defined as the freedom from health-care responsibilities, and not as the freedom to live without the fear of catastrophic health care costs. 

·         They need to tell us how they – the political magicians they claim to be – can reduce healthcare costs without reducing the availability of coverage to the American poor; and they need to test that assertion, in all its detail, in the court of public opinion.

 Healthcare is too important an issue – and too large a part of the American economy – to be discussed in clichés and sound-bites. In truth, it’s actually too important an issue to be resolved by nine unelected judges attempting to divine how long-dead eighteen century men would respond to twenty-first century problems. But there’s no avoiding that. The Supreme Court will have its say, and what those nine judges decide will seal the fate of the ACA one way or the other. So as we wait for them to do that, we do desperately need to know what would actually happen should the ACA be struck down and there be a Republican presidential election victory in November. We need to know all that well in advance.

 Of course, as we saw earlier when reviewing Republican positions on taxes,[40] on business regulation[41] and on federal deficits,[42] to the degree that we do discover what a Republican victory in November will actually mean, the likelihood of that victory will diminish accordingly. That is presumably one rather important reason why the four remaining Republican candidates are not telling us, in the detail we require, what exactly they will create in the ACA’s place. We need to press them to do so.

First posted at www.davidcoates.net