Ever since Congress adopted the Affordable Care Act Republicans have been committed to repealing it. In fact, many party members up for re-election successfully employed the mantra "repeal and replace Obamacare" during their campaigns. Now that they have a majority in both houses and a President in the White House, Republicans face the daunting prospect of needing to deliver. They are finding out that it is much easier to make bold political promises than it is to follow thru on them, and that replacing an intricate framework for one-sixth of the economy is easier said than done. Lousise Radnofsky, writing in the Wall Street Journal, summarized the conundrum as follows: "Republicans are caught between competing forces: a desire to take bold steps in remaking health care along conservative lines, and the political restrictions that come with a six-year old law that is already entwined through the American health system." She also published the results of a new Wall Street Journal/ NBC New poll that finds that right now 45% of Americans think that the health law is "a good idea," for the first time out-polling those who dislike the law.
During a recent interview, President Trump announced that he has a plan that will simultaneously repeal and replace the Affordable Care Act. He has just been waiting for his nominee for Secretary of Health and Human Services, Rep. Tom Price, R-Ga., to be confirmed. (Under pointed questioning from senators considering his nomination, Dr. Price admitted that he was unaware of such a plan). To kick-start the process, Trump's first executive order directed government agencies to scale back as many aspects of ACA as possible. Meanwhile both the House and the Senate approved budget resolutions that would allow Republicans to repeal the tax and spending provisions of ACA with simple majority votes, bypassing a possible Democratic filibuster. House Speaker Paul Ryan referred to these as part of a "rescue mission."
Although the mechanism for "repeal" much of the law was agreed upon, proposals on how to replace what is taken away are nowhere near complete. Some have advocated for repeal, and delay implementation to some date beyond the next election cycle, which is two years away. This strategy was suggested, in part, because they really don't agree on how to proceed, and partially because many Republicans have serious concerns about political fall-out during the upcoming mid-term elections. An estimated 22 million Americans who gained coverage under ACA could lose their insurance. Many more have pre-existing health conditions insurers were able to deny coverage for, or who were charged excess premiums prior to ACA. Repeal of the Medicaid expansion prompted by the law will not only remove millions of low-income Americans from their insurance coverage, by converting the program to so-called "block grants" to the states will effectively eliminate it as an entitlement. The American Hospital Association estimates that during the 2018-2026 period hospital operating costs will increase by $400 billion. And, on top of these and other disturbing statistics, budget conscious legislator point out that, during the next ten years , a suitable replacement for Obamacare will add an estimated $9.7 trillion to the national debt.
Given that the discussion in Washington has turned into a political circus lacking a safety net, communities across the country are attempting to anticipate the consequences of repeal, and are constructing responses. A few weeks ago I became aware of one of these efforts in a community not far from Seattle, Washington. Its key health advocate expressed the group's mindset as follows:
"In a rural county of 33,000 people, I am helping to organize a network of community health advocates. The goal is to support our neighbors in wellness. That means helping people learn about health resources, access care and have a health plan that is adequate and affordable. Two groups are key to this organizing effort: a resource team of individuals with experience in education and care; and an outreach team with representation from a broad base of community and neighborhood organizations. Our aim is to provide basic training and information for as many local groups as possible throughout the county, so that each will have their own community health advocate. Two examples: A volunteer health advocate is available each week at the town food bank, and volunteer community health advocates are serving in congregations to assists individuals who have unmet medical and mental needs. We are reaching out to senior groups, social service programs, voluntary organizations of all kinds, small businesses, parents and student groups, recreational programs and cultural groups.
Since both political parties have an important role to play in our health conversations, I am also interested in how, with the help of the local Republican and Democratic organizations, community health advocates could be made available in every precinct in the county.
Wellbeing is not simply an individual matter. When we are ill we need the support of others. Very few of us can afford to save or bear the cost of care for an accident, a long-term illness or a chronic condition. None of us alone have all the knowledge we need to lead healthy lives. Healing and wholeness involves encouraging relationships with others, the help of family and friends, and the support of the wider community."
The principal organizers of this effort are hard at work developing a structure that will allow them to replicate successes across their county, and ultimately across the country. Perhaps our politicians should stop their ideological grand-standing, and consider elements from attempts designed to offset the anticipated changes people are worried about.
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