Obamacare on life support as GOP takes over White House, Congress

In the end, Obamacare may have simply proved to be too unwieldy to work.

Always a tenuous compromise, the Affordable Care Act managed to cut the rate of the uninsured to historic lows. But President Obama’s chief accomplishment is a prime target for repeal after repeated stumbles by his administration, which botched the launch of the exchanges, saw its plans whittled away by the federal courts and refused to negotiate major changes with a hostile Congress.

And the law’s most contentious provision — an individual mandate requiring Americans to get insured or pay a tax penalty — failed to force the kind of buy-in from young and healthy enrollees that the president and his team were counting on.

“Think about this. The law says you have to sign up if you are not eligible for other coverage. If you don’t sign up, you will be fined. If you are low-income, the government will pay part of your premiums. Yet by the fourth open enrollment, less than half of those eligible have signed up,” said Robert Laszewski, a health policy consultant in Alexandra, Virginia.

The law passed Congress in 2010 without a single GOP vote, and quickly made headway. Young adults up to age 26 were allowed to remain on their parents’ plans, and the administration mandated a number of treatments that must be standard in health policies.

Those with pre-existing conditions were also guaranteed the ability to buy plans.

But Republican governors resisted the twin pillars of the law — many balked at setting up their own web-based exchanges where customers can qualify for taxpayer subsidies, and 19 states refused to expand Medicaid, saying it would bust their budgets, after the Supreme Court deemed it optional.

Then came the fall of 2013 and the botched rollout of the plan’s health exchanges, where those lacking insurance were to be able to buy coverage. And Mr. Obama’s promise that people who liked their insurance could keep them was proven false, as insurers sent a flurry of cancellation notices to customers whose coverage didn’t meet Obamacare’s requirements.

Now in their fourth year, the exchanges are troubled. Premiums for popular “benchmark” plans are spiking by an average of 22 percent nationwide, and roughly a third of counties have only one insurer to choose from on their Obamacare exchange.

Meanwhile, too many people chose to pay a penalty instead of signing up under the program. The IRS says 6.1 million paid the Obamacare tax in 2015, while another 12.2 million claimed an exemption to avoid paying the tax or having coverage.

Republicans who swept in to power with incoming President Donald Trump in November say the law’s stumbles have confirmed their worst fears, although Mr. Obama says his critics deserve a share of the blame, and say the law is working for those who now have coverage.

The latest figures show more than 20 million gained insurance because of the law.

Yet up to 9 million people in the individual market still don’t qualify for taxpayer assistance under the program and will face the brunt of soaring rates.

The Obama administration “never conceded that the working and middle class are being harmed by the program,” Mr. Laszewski said. “The result of that was the 2016 election, when Trump did focus on the failures and used Obamacare as a central issue on the way to victory.”

Republican leaders took steps last week to leverage a fast-track budget process that paves the way for a repeal vote, while avoiding a Democratic filibuster, though they haven’t coalesced around a firm replacement.

Suddenly Democrats say they’re open to fixes that would increase the federal footprint in health care — namely, a government-run “public option” to compete with private plans and more generous subsidies to draw more people into the marketplace.

A recent Kaiser Family Foundation poll said only 1 in 5 Americans want Congress to repeal the law without a replacement in hand.

Obama administration officials say a repeal would send the health markets into a tailspin: Cancer patients will scramble to afford treatments, insurance companies won’t know how to price their products and will drop out of the market, while hospitals will be saddled with the costs of uncompensated care.

“We are starting to see that movement from rhetoric to reality,” departing Health and Human Services Secretary Sylvia Mathews Burwell recently told a roundtable of reporters.

Republicans insist they will smoothly bridge enrollees to a plan that provides “universal access” to coverage that Americans want. Their blueprints call for a plan that replaces heavy federal mandates with aged-based tax credits and unleashing market forces to make a broad array of plans more attractive.

However, the GOP wants to continue allowing young adults to stay on their parents’ plans until age 26 and ensure that people with pre-existing medical conditions can get covered, so aspects of Mr. Obama’s health legacy should survive.

Still, “it’s tough to see how it will be a positive thing” for Mr. Obama to take credit for the reforms, only to see his signature law repealed, said Lanhee J. Chen, a fellow at Stanford University’s Hoover Institute who advised 2012 GOP nominee Mitt Romney on health policy. “Unless he wants credit for trying.”