Donald Trump likes to pick and choose which traditionally Republican policies he supports, particularly concerning social programs.  But he is all Republican concerning Obamacare, promising to repeal the Affordable Care Act despite the fact that abolishing its major provisions would hurt most those who most ardently supported Trump.  In doing so he has bought into a major dilemma that recent Republican partisanship-before-country policies have created.

There are some things about major social programs that many Republicans have never liked.

Some Republicans opposed FDR when he proposed Social Security in 1935. To this day, House Speaker Paul Ryan and others continue to look for ways to privatize the program. Trump says he will leave it alone, but since his word is subject to change from tweet to tweet, we’ll see about that.

A majority of congressional Republicans opposed LBJ when he proposed Medicare and Medicaid in 1965. Again, Ryan and others continue to try to reduce/modify/privatize those programs. Trump claims he supports Medicare but he may be planning cuts in Medicaid.

Republican opposition to Social Security and Medicare seems like a day at the beach compared to their fight against President Barack Obama’s Affordable Care Act (ACA). The House has had more than sixty show votes on repealing Obamacare in the past several years, and with the help of the Republican-controlled Senate they actually got a bill to Obama’s desk, which was vetoed. Republicans have been obsessed with repealing the ACA.

So now they have their chance. With Republican control of the House, Senate and White House they can do what they want with Obamacare. They have had control of both Houses of Congress for the past two years, so you would think they could pull a previously drafted bill off the computer to allow immediate and complete action this month. Not so.

The original objective was simply to repeal the ACA, but the plan has long been couched in the phrase “repeal and replace.” It seems that reality has struck some Republicans. The “replace” part is a little complicated. Actually, a lot complicated.

The complications include:

• More than 22 million Americans, previously uninsured, now have health insurance through the ACA. A record number of participants have signed up for the program during the current enrollment period.
• Subsidies of one form or another have indeed made the insurance “affordable” for many.
• The prohibition on denying someone medical coverage because of a pre-existing condition has proved very popular.
• So has allowing adult children up to the age of 26 to be covered by their parents’ medical insurance.

As the Republicans search for the ideal piece of replacement legislation – a search that has been going on for six years – they are running right into these messy and very popular complications.

Some of the Republicans like Speaker Ryan seem to think that they have found the perfect alternative policy, and it even uses fewer than 140 characters in a tweet – “universal access.” Basically that means not striving for universal coverage, where no American need go without medical insurance. Instead Ryan wants to provide a system where everyone has “access” to coverage. Actually, universal access was the system in place prior to 2010, when the ACA was approved. “Universal access” is sort of like thinking we all have “access” to buying a Mercedes, a Rolex, or a house in Palm Beach. Access without money equals no access.

Republicans seem to realize that they cannot eliminate the ACA with a flick of a switch. Americans are already signed up for 2017. Insurance companies have planned their finances with income from those coverages in place. Hospitals that have not found it necessary to cover free care in the same volume as they did pre-ACA would find major holes in their budgets if the law were immediately repealed.

So now there is talk about phasing the Obamacare shutdown over two or three years. With all that great universal access, the thinking goes, those 20 million-plus people should be able to figure out something for themselves in that amount of time.

The Republicans also seem to realize that the pre-existing conditions and age-26 provisions are things that their constituencies really like. So let’s keep them. But how do you pay for them?

One of the basic premises of the ACA was and is that when you have a health care and insurance system that offers popular features such as these you need as many people as possible participating to spread the costs. Without those revenues, the pre-existing and age-26 features are not possible. Eliminate the individual mandate as well as those for businesses and the entire underpinning of those features is gone.

A really ironic dilemma that the Republicans in the House now face concerns their attempt to undercut the law in federal court by challenging the validity of appropriations that provide subsidies to participants. The House Republicans have made some headway in court in eliminating those appropriations, claiming that Congress has not annually approved such spending.

The lawsuit was great for the Republicans with President Obama in office and even if Hillary Clinton had won. The reason is that if a court actually knocks out the spending, that would lead to insurance company losses and their likely departure from the program. Many people might drop their ACA coverage. That would all lead to the collapse of Obamacare.

The election of Donald Trump, however, creates a problem because the chaos that would ensue from the end of the subsidy appropriations would fall on congressional Republicans and Trump, who haven’t figured out the “replace” part of what they want to do. For that reason Republicans are now trying to stop or slow down the lawsuit they started. If that does not work, then the Republicans are not prepared to deal with the chaos, and they will be forced to approve billions in appropriations to keep Obamacare running.

Another even greater irony of the Republican march to repeal Obamacare is that the largest portion of the population that will suffer from the loss of medical insurance will be the very people who supported Trump most strongly in the election. Numbers will vary from county to county in the rust belt and the coal belt, but here is a great specific example recently noted in the Washington Post. The good citizens of Whitley County, Kentucky supported Trump with 82 percent of their vote. In Whitley County, however, the rate of uninsured people declined 60 percent under the ACA. Evidently they did not take him literally when he spoke about ending Obamacare.

The Post also reported “[o]thers who didn’t take Trump literally may soon face the same dilemma. The Urban Institute estimated this month that under the partial repeal plan previously passed by Republicans in Congress, 30 million people would lose insurance, 82 percent of them would be in working families and 56 percent would be white. Among adults who would lose insurance, 80 percent don’t have college degrees.”

The Atlantic’s recent report on the planned repeal of Obamacare noted this about West Virginia, a state that voted a 69 percent majority for Trump:

West Virginia, which has been wracked by public-health problems, pollution, and has the most per-capita drug deaths in the country, has had to embrace Obamacare’s Medicaid expansion and subsidies in order to provide affordable healthcare for all those coal miners, other low-income workers, and their extraordinary rates of disease and disability. While premiums for exchange plans have increased by double digits across the state, that largely reflects the cost of covering such a sick pool of rural enrollees, and most people in the state will never see those increases because of subsidies.

States supporting Trump have recently led the nation in 2017 program sign-ups through the federal HealthCare.gov website. The top five states were Florida (1,300,000 enrollees); Texas (776,000); North Carolina (369,000); Georgia (352,000); and Pennsylvania (291,000).

None of what I am reporting here is meant to indicate that there have not been or do not continue to be some problems with the Affordable Care Act. The program originally had sign-up website problems, but those were long ago resolved. Doctor availability did not work out as promised.

More recently there have been large spikes in premiums. There was no history on who would sign up or how much those men, women and children needed medical care. The premium increases that are occurring in 2017 result from the insurance industry now having such information. Things are likely to level out as actual coverage experience becomes known. In the meantime there are subsidies for those who qualify and need them – unless that Republican lawsuit wipes the subsidies out.

Given the importance of medical coverage for more than twenty-two million people and given factors such as the pre-existing conditions and age-26 benefits, we are much more likely to see Obamacare amended, not replaced. The basic justification and premise of the law is solid. This will probably take two or three years, but in the end the law will be stronger and the public interest will be served.

Jim Keane

My friend and colleague Jim Keane passed away unexpectedly shortly before Christmas. There are thousands of people who also consider Jim a friend and colleague.

I first knew Jim some forty years ago as the brother of my boss at the Erie County Legislature, Dick Keane. Then there were Jimmy’s years on the Buffalo Common Council and as a candidate against Jack Kemp and Dennis Gorski.

In 1997 I joined the Gorski administration as budget director. Jim by then had risen to Deputy County Executive. We worked closely on many projects.

In 2002, as the movement to remove Steve Pigeon as Democratic Chairman grew, Jim and I were opponents, and Len Lenihan was the third candidate for chair. Considering what was at stake and where our respective support was coming from, that could have been a real problem which might have continued the fragmentation of the party. But it didn’t happen. We continued to be friends and colleagues. Things worked out.

We will all miss Jimmy’s friendship, wisdom and good humor. Rest in peace, Jimmy.