Over the course of the month, President Donald Trump has signed executive orders to halt the cost-sharing reduction payments that help insurers provide inexpensive plans to low-income enrollees, and to loosen regulations in order to allow insurers to offer stripped-down, lower-priced coverage to healthier people, thereby potentially trapping the sick in expensive, high-risk pools. Although the GOP's repeated attempts to "repeal and replace" the health-care law have failed, it still seems likely the future of the ACA—and many of those who rely on it—will remain in a precarious position for the foreseeable future.
As Graham-Cassidy picked up (and ultimately lost) steam in September, the ACA also faced a simultaneous, albeit largely symbolic, "repeal and replace" effort from the left: Senator Bernie Sanders' (I-Vermont) long-anticipated Medicare for All bill, co-sponsored by 15 Democrats in the Senate. Even the bill's most enthusiastic backers admit it has precisely no chance of passing right now—not only do Republicans currently control all three branches of government, but a majority of Democrats are still dedicated to expanding access to health care by improving the ACA. For those Democrats less inclined to pursue a complete systemic overhaul, the unprecedented single-payer groundswell sparked swift resentment over fears that Sanders' fantasy plan could lend Graham-Cassidy a welcome distraction as it shored up a critical mass of support. "Never understood why Sanders didn't wait till after the 9/30 reconciliation deadline to release his bill," Ezra Klein tweeted. Bill Scher of Politico asked, "Why should Democrats prioritize junking what was just successfully defended, at enormous political risk, when there are so many other moral imperatives that warrant a robust and urgent policy response?"
But such arguments assume that the most politically resilient health-care system is the one that is already in place. For anyone sincerely concerned about the potential havoc Republicans could unleash, it's worth noting that the ACA's brittle framework helps facilitate such partisan manipulation in the first place.
One major structural drawback of the ACA—which too few people seemed to notice until Trump was in office—is the legislation's dependence on public officials' active and continuous support to function. It's safe to say this won't be offered by the Trump administration, which has already demonstrated several ways of making the law less effective. Even before Graham-Cassidy's failure, the White House announced it would be cutting down the open enrollment period for individual coverage on the ACA's state exchange markets by half, from 90 to 45 days total. Advertising budgets to educate potential beneficiaries about the open enrollment period and marketplace options were also cut by 90 percent, in addition to a 41 percent cut to in-person enrollment assistance. For the 31 percent of those seeking such help who lack a home Internet connection, this service is particularly vital—and even those enrolling at home will face inconvenient website outages every Sunday during the open enrollment period. One former director of such ACA outreach estimates such initiatives are responsible for some 40 percent of enrollments; another study in Kentucky found that cutting television ads alone caused a 20 percent drop in participation statewide.
The whole concept of an "open enrollment" phase only makes sense if you're trying to minimize a business' exposure to risk.
Even those who do manage to enroll in a marketplace insurance plan aren't guaranteed a robust program. Trump had already hinted he'd halt the law's cost-sharing subsidy payments for months before last week's executive order, the uncertainty over which led insurers to raise prices for coverage, with marketplace premiums spiking by over 60 percent in certain counties. The problem is especially bad in counties with only one insurance provider, which, in turn, enjoy a sort of de facto monopoly power when it comes to pricing. And while the actual impact of many GOP tactics have let to be seen, they pale in comparison to one clear example of how hostile lawmakers have already undermined the health-care law: Some 2.5 million Americans fall into the so-called "coverage gap" caused by states who refused the Medicaid expansion, effectually barring those individuals from the health-care system.
Of course, supporters of the ACA deplore these efforts, and correctly point out that the law would work infinitely better if not subject to acts of sabotage. But it's possible to condemn Republican goals and methods with regards to health care while also recognizing that laying the blame for Obamacare's woes solely at their feet is incomplete. After all, every one of the strategies currently being deployed by the GOP to undermine are uniquely applicable to the ACA's system of managed competition between for-profit insurers. The whole concept of an "open enrollment" phase only makes sense if you're trying to minimize a business' exposure to risk; single-payer systems' enrollment is unaffected by employment or lifestyle changes and have automatic or one-time enrollments. Unsurprisingly, this simplified process—wherein the intimidating manual of itemized ACA plans is whittled down to one entry—demands less advertising and outreach as well.
The stark contrast in potential for sabotage between the ACA and Medicare for All is even more evident in the structure of the market itself. When politicians engage in heated debates over how best to "stabilize the exchanges" set up in each state, they're really talking about how to orchestrate a situation wherein patients and insurance companies' shareholders all benefit at the same time—and that is astoundingly hard to do. Not only do insurers need to charge premiums that allow them to clear overhead and profit margins beyond the cost of care, but marketplace exchange participants are disproportionately more likely to be sicker or have preexisting conditions that locked them out of the individual market before the ACA. As such, this "stabilization" process requires near constant tinkering to persuade insurers that it's to their benefit to stay in the marketplace, lest one payer should find itself the last option left in a given county. And even after the long, laborious process to reach the unlikely equilibrium of insurers and patients reaping simultaneous benefits, the balance could be immediately thrown off-kilter by any number of political methods. Needless to say, in its capacity as a unified insurance pool at the national level, single-payer system would not have a coverage gap imposed by governors' refusal to expand Medicaid.
That isn't to say single-payer systems are completely impervious to sabotage. There is no robust social democratic program on Earth that isn't somehow targeted by those who have the most to gain from its contraction or demise. But it's telling to examine the difference between the vulnerability of the ACA—pushed to the brink of disaster three separate times this year, only to be saved by unprecedented groundswells of activism—and the United Kingdom's fully socialized National Health Service, whose repeal is politically unthinkable even as its efficiency ebbs under austerity measures imposed by the Tories.
It is significant that the grassroots efforts to save the ACA against Graham-Cassidy and other GOP bills earlier this year overwhelmingly focused on fighting cuts to Medicaid, the most successful and widely utilized portion of the health-care law. Medicaid's ability to galvanize illustrates a perennial truism of politics: Effective social democratic programs generate constituencies who will fiercely defend them. If you imagine substituting the state-administered Medicaid program with federally run Medicare for All, it's easy to envision the far more staggering political obstacles that would loom against would-be repeal-and-replace efforts.
At the very least, we have exactly no reason to believe that defending and improving the ACA will prove to be a path of less resistance than enacting Medicare for All. While the latter might be harder to implement, so too is it harder to take away.