For those still stunned by November’s election results, Donald Trump shattered any lingering hope of finding refuge in denial, as he made good on his campaign promises to abolish the Affordable Care Act (ACA). A full week before being sworn into office, Trump ordered the Republican leaders in the Senate to begin the process of repealing and replacing the Affordable Care act simultaneously. Within one day, the Senate voted 52 to 48 to begin the process of repeal, even though all the Democratic senators, and one Republican, Rand Paul, voted against it, with most of them vocally protesting the fact that there is no proposed bill to replace it. In fact, any semblance of how to replace health care for the 22 million Americans now covered under the Affordable Care Act is completely unknown. Based on actions taken by the Senate and the House, the four key committees that deal with health care have been given until January 27 to come up with plans to cut revenues for key components of the Affordable Care Act. By cutting funding — rather than repealing the act itself — the repealers need marshal only a simple majority to achieve their ends. Given the strong majorities enjoyed by Republicans in both bodies, this route is all but invulnerable to filibuster.
Shortly after Trump’s election in November, Sansum CEO Kurt Ransohoff expressed cautious hope that Trump should be taken seriously but not literally. A few weeks later, however, Ransohoff was forced to temper that initial optimism. Trump, he conceded, needed to be taken both seriously and literally. For the 22 million who bought insurance from any of the thousands of health-care exchanges created by the Affordable Care Act, this could prove to be a serious problem. To date, no Republican, neither President-elect Trump nor congressional leaders, has provided any specifics for how to replace the Affordable Care Act — and for good reason. It won’t be easy. It might, in fact, be impossible. Only by making participation mandatory as the ACA does — even for young, healthy adults — would the risks and revenues be balanced out for the insurance companies. Left unanswered are scary multibillion-dollar questions as to how those with pre-existing conditions can be guaranteed coverage outside the rubric of the Affordable Care Act. Without the Affordable Care Act, how will insurance companies be prevented from imposing the lifetime coverage caps that Obamacare eliminated?
It’s telling that Santa Barbara’s newly elected congressmember, Salud Carbajal, took on the Republican repealers in his first speech from the House floor. “This is not a game,” he concluded. Forty-five thousand of his constituents, Carbajal said, would lose access to the health care they got only through the Affordable Care Act. To repeal first and replace later, he declared, was “simply reckless governance.”
The numbers for Santa Barbara County alone are staggering. Beyond the 45,000 beneficiaries Carbajal alluded to, the Affordable Care Act also extended Covered California and Medi-Cal to 55,000 people in Santa Barbara County who had previously been ineligible. According to area health administrators, this seemingly esoteric bureaucratic adjustment brings in no less than $123 million a year in federal dollars to pay the health-care costs for individuals previous ineligible. Thanks in part to this, the Santa Barbara Neighborhood Clinics — frontline providers for those most challenged accessing the health-care system — have managed to achieve financial stability for the first time in years. Without the primary care services provided by these clinics, Santa Barbara’s emergency rooms will, once again, become dramatically more crowded.
For all the problems associated with the Affordable Care Act — with rapidly rising premiums, some plans costing too much and providing too little coverage — it remains to be seen what alternatives the Republican majority will offer. To date, such details have been conspicuous by their absence. In their stead are general references to tax credits, the ability for intrastate insurance competition, vouchers for Medicare, and block grants for Medicaid.