We're less than three weeks away from the dawn of a new era in Washington, and the engine of that transformation will be the Republican Congress. Having suffered for eight long years under a president who stood in the way of their noble efforts to turn America into a paradise of prosperity and morality, they are counting down the days until they finally get what they want, until their legislative blessings burst from the Capitol building in a wondrous eruption of virtue and wisdom, make a quick stop on Pennsylvania Avenue for President Trump's signature, then wash over a grateful nation.
Some of the items on their long, long list of priorities may be relatively easy to accomplish, but others are trickier. And none is more fraught with political peril than their single most important goal: repeal of the hated Affordable Care Act.
Since the election, there has been reason to believe that Paul Ryan and Mitch McConnell might want to tread carefully on repealing the ACA, but they're sending the message that the throttle is wide open. The new Congress will be sworn in on January 3, and as The New York Times reports, "Within hours of the new Congress convening on Tuesday, the House plans to adopt a package of rules to clear the way for repealing the health care law and replacing it with as-yet-unspecified measures meant to help people obtain insurance coverage." McConnell insists that "The Obamacare repeal resolution will be the first item up."
Sure, they don't yet know what they want to replace the ACA with (though Trump did promise during the campaign that the replacement would be "something terrific"). But that can all be worked out later. Once Americans find themselves blissfully unburdened from the law, they won't much care about the details.
Now let's get serious for a moment, as we consider what repeal will actually bring—and what Republicans will be wrestling with. First, repealing the ACA would immediately toss well over 20 million people off their health coverage, most particularly the 12 million who are covered thanks to the law's expansion of Medicaid and the nine million who are receiving substantial subsidies to buy private insurance on the exchanges (figures are from Charles Gaba, who tracks these data more comprehensively than anyone). That's not to mention the 52 million Americans under 65 who have pre-existing conditions and would be made vulnerable if the ACA's rule that prevents insurance companies from denying them coverage is repealed. And that's just part of what would happen, from increasing the deficit, to undoing Medicare payment reforms, to removing subsidies small businesses get to insure their workers.
Of course, Republicans say that with their terrific free-market plan (whatever it turns out to be), everyone will do better in the end. That idea happens to be ludicrous if you look at what they're considering, though that's a topic for another day. But even if you accept it, what can't be denied is that their changes will take time, perhaps lots of time, to produce the outcomes Republicans hope for. The idea is that while you and your family might get kicked off Medicaid now, once the Republican reforms work their free-market magic, insurance will become cheaper and cheaper, to the point where you'll be able to afford it even on your $20,000 salary.
So even in the best of circumstances, there would a positively gargantuan amount of short-term suffering and eventually, perhaps, things would work out for the best. That suffering will play out in very visible ways, with horrifying stories reported in the media of families losing their coverage. Just wait until we hear about people dying—and make no mistake, people will die—when they can no longer access health care.
And the Democrats who have had such trouble defending the ACA in all its complexity will find themselves with a new political and rhetorical focus as they attack Republicans' plan to unleash chaos on the American health-care system. The political dynamic of health care in the last few years, in which the president's party gets the blame for anything that goes wrong in the system, whether it was their doing or not, will now work against Republicans. They'll probably try to say it's really Barack Obama's fault, but with complete control of government, and with years of promises of how great things would be once they got their paws on the health-care system, no one will believe them. And as Republicans know well, it's a lot easier to attack something than it is to propose your own complicated solution.
I have no idea what Republicans in Congress are saying to each other in private as they contemplate the catastrophe they're about to initiate. Perhaps they genuinely believe that with some health savings accounts and high-risk pools, they really can create a health-care paradise and Americans will reward them for their benevolent genius. Or perhaps they think they can win the spin war, no matter how many Americans suffer once repeal takes effect—though their own actions suggest they don't think so, given that they seem to be leaning toward a "repeal and delay" plan, where they repeal it now but delay the irepeal's mplementation until after the 2018 midterms—or even the 2020 presidential election.
Or perhaps—and this is what's most likely—McConnell and Ryan are fully aware of the repeal's political danger and the ghastly toll it will take on people's lives, but they feel they have no choice. After saying since 2010, when the law passed, that it's the most vile tool of statist oppression since Stalin's gulag, and after holding 60 votes to repeal it, and after saying again and again to their base that they'd set it aflame and stomp on the ashes the instant they could, they can't possibly avoid repeal. Keep in mind that these leaders have spent that entire time terrified of their base and the Tea Party extremists in their own caucus. When that base called them cowards and appeasers, their response was "We're right with you, but what can we do? Until we get a Republican president and a Republican Congress, we can't kill Obamacare. But make sure you keep hating it with all your might until that glorious day arrives."
Well now that day is here, and they have to deliver. And they can no longer blame anyone else for the harm they do.