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What will replace Obamacare?

On Jan. 13, Elise Stefanik voted with the Republican majority in the House in favor of taking the first step toward repealing the Affordable Care Act, also known as Obamacare. She says she prefers a three-year period before repeal goes into effect, in order to assure that there will be a viable plan to replace it.

The problem is this: Elise Stefanik voted for a full repeal of the Affordable Care Act almost two years ago in February 2015. Republicans have voted 56 times to repeal it. Shouldn’t they already know what to replace it with? Before rejecting a plan which has extended health care to almost 20 million people, many with pre-existing conditions, shouldn’t Stefanik already have a clear idea of what kind of health care reforms she does support?

Of course, the ACA itself was based on a Republican idea and was patterned after the plan introduced in Massachusetts by Mitt Romney when he was governor of that state, but Republicans disowned it once Obama embraced it. Since then, various other solutions have been circulating in conservative circles about how to reform health care after repeal of the Affordable Care Act, but some are really no solutions at all:

¯ One concept is to allow insurance companies to sell plans across state lines. Some states have few requirements for what health insurance must cover, so theoretically such plans would be cheaper than those sold in New York, which has higher standards. So you might be able to buy a cheap out-of-state plan, but it may not cover much if you actually need it. This notion has been around for decades, but insurance companies have shown no enthusiasm for it, partly because of the difficulty they would have in setting up provider networks in each state.

¯ Another proposal is to expand Health Savings Accounts, in which you can set aside a fund of money to be used to pay for your own health expenses, and those dollars would be tax free. This may be a good idea for those with enough disposable income to fund a Health Savings Account, but for people living paycheck to paycheck, such an account would be so unattainable as to be laughable.

¯ Another idea is to have high-risk pools, grouping people with pre-existing conditions such as cancer, asthma or diabetes into one group. Even with subsidies, it isn’t hard to imagine how expensive insurance would be for the people in this group.

¯ Republicans also have proposed using block grants to give control of Medicaid to the states. This would undoubtedly create large disparities in who qualifies for Medicaid from state to state. The more conservative states, that have an ideological objection to public assistance, certainly would find ways to disqualify many recipients.

None of these ideas is a substitute for the subsidies that the Affordable Care Act offers to those eligible so they can actually buy a high-quality insurance plan, nor to those who qualify for Medicaid, which has been expanded under the ACA to include more people.

So what is the advantage of waiting for three years after voting to repeal the Affordable Care Act before members of Congress like Stefanik have to come up with a replacement plan? Such a “repeal and delay” plan may be a clever attempt to have it both ways — to appease constituents who have a visceral resentment toward ‘Obamacare” by repealing it now while leaving it in place for three years and thus not alienating the millions of people who would lose coverage until after the 2018 midterm elections. The Congressional Budget Office has estimated that 19 million would lose coverage in the first year after repeal, with the number rising to 24 million in a few years. Perhaps Republicans like Elise Stefanik know full well that however they choose to repeal the Affordable Care Act, what follows will leave many more people with inferior coverage or no coverage at all. From a political point of view, delaying the impact of repeal for three years makes sense to avoid a backlash from constituents who realize that they no longer can afford health care.

The fact is that health care is expensive, especially in this country, where we spend more on health care than any other industrialized country and yet have worse outcomes in terms of life expectancy and infant mortality rates. The Affordable Care Act is not perfect, and in my opinion, a single-payer plan or at least a public option would have been preferable. But the ACA does offer a framework in which many more Americans finally have health care, instead of being the only industrialized Western democracy that does not guarantee health care to all its citizens. The ACA also has the potential to provide incentives for reforms that would make our health care system more efficient and less wasteful over time — a long-term but extremely valuable provision.

Of course, Obamacare is not perfect, and it can be made better. Unfortunately, Republicans in Congress steadfastly refused even to consider reasonable reforms while President Obama was in office, putting the political advantage of criticizing the law ahead of doing something to improve it. Now the ball is in their court, but instead of taking a shot and offering a substitute, Elise Stefanik and other Republicans think the better strategy is to play out the clock and wait till after the midterm elections before making a move. In the last week, Donald Trump has hinted via Twitter that he has a fantastic plan to replace the Affordable Care Act immediately — but so far he isn’t telling anyone one what it is. Based on his past performance, I will believe it when I see it.

We deserve better. Elise Stefanik voted several times to repeal Obamacare and has had plenty of time to formulate her ideas on what should follow it. Her constituents deserve to know now where she stands before she votes again for repeal —because unlike in the past, this time when she votes for repeal, it will have a real impact on real people.

Rosalie Fontana lives in Bloomingdale.

Sources:

Thompson, Maury, “Stefanik wants three-year repeal and replacement process,” Adirondack Daily Enterprise, Jan. 16, 2017

Health Reform Votes, Representative Elise Stefanik, www.healthreformvotes.org/congress/412648

Berman, Russell, “Republicans Offer a Plan to Replace Obamacare” The Atlantic, June 2016, www.theatlantic.com

Jacobson, Lewis, “What would the impact be if the Affordable Care Act is repealed?” Politifact, Jan. 5, 2017, www.politifact.com

“US Health Care from a Global Perspective,” The Commonwealth Fund, www.commonwealthfund.org

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