Uncertainty Alone Could Kill Obamacare

Federal exchange enrollment is down, and insurers are threatening to pull out, as Republicans debate how to address the law.


Paul Hennessy/Polaris/Newscom

Obamacare is shrinking. But Republicans are struggling—predictably—to figure out what to do about the law. Over the last week, number of the party's legislators have quietly switched from talking about repealing and replacing the law to talking about repairing it. The once-rapid timeline for repealing the law has been extended. In an interview over the weekend, Trump, who just last month said that a replacement was "very much formulated down to the final strokes," suggested that the process of reforming the law could take a year or more.

The reason it could take that long is that the legislative process is not conducive to swift movement, especially on something as complex as health care policy. As Trump awkwardly explained last night to Fox News host Bill O'Reilly, "It statutorily takes awhile to get." But, Trump said, "We're going to be putting it in fairly soon, I think that, yes, I would like to say by the end of the year at least the rudiments but we should have something within the year and the following year." That does not sound like a plan that is or ever was formulated down to the final strokes.

Yet even in the absence of legislative action to repeal Obamacare, a key part of the program could simply wither away. Regardless of whether Republicans take steps to eliminate the law, the current dynamic of Republican opposition, policy uncertainty, rising premiums, insurer losses, could drive away both insurers and customers from its exchanges, leaving only an empty husk of a program in its place. It is a dynamic that reveals just how fragile the law is—and also how difficult it is to fix.

We're already seeing some signs that participation in the law is falling. Late last Friday, the Trump administration released this year's final enrollment figures. For the first time, total enrollment in the federally run exchanges is down, dropping from about 9.6 million to about 9.2 million.

Last year, supporters of the program pointed to indications that the program might be growing as a measure of its overall health. The drop in enrollment may not by itself be a death blow, but it should be understood a clear sign of its weakness.

Some of the law's supporters are blaming the decline on a decision by the Trump administration to not run about $5 million worth of ads (out of a total $60 million campaign) during the final days of sign-ups, when there is usually a spike in enrollment. This year the spike was smaller than normal—about 376,000 in the last two weeks of January compared to about 687,000 last year. Was the decline a result of the ads being yanked? Perhaps in part, but it's also worth noting that the decline started before the ads were pulled. And the Trump administration partially reversed the decision to yank the ads after a single day. In addition, some of the ads were run anyway by a left-leaning digital advertising firm.

Causality is always difficult to prove when it comes to advertising. I would not be surprised if the decision to pull the ads at what is usually a key moment for sign-ups played some part. But it seems unlikely that the ads themselves were the critical factor. Instead, it is more plausible that the decline was a result of the combination of significantly higher premium prices and general uncertainty surrounding Obamacare's future. Why sign-up for something that may not exist—at least not in its current form—six months or a year from now?

In any case, any program that can be undermined by the partial retraction of 8 percent of its advertising budget is not one that is obviously healthy and sustainable.

Customers aren't the only ones who look increasingly wary of Obamacare either. Major health insurers have already scaled back their participation in the law's exchanges. And some have hinted that they may pull back further out of caution about the program's uncertain future. The head of Aetna, which last year ended participation in some state exchanges, said the company many take further steps to pull out of the program, "given the unclear nature of where regulation's headed."

The underlying logic for insurers is similar to the logic for consumers: Why participate in a program that may not be around for much longer? That question is especially pressing for insurers, since they need to develop prices and plan offerings for the 2018 coverage year over the next few months.

This is the essential Obamacare conundrum for Republicans: Thanks to its unified control of Congress and the executive, the party can take steps to unwind the law relatively rapidly, either through legislative or executive action. But that would mean destabilizing the individual insurance market, unless some replacement could simultaneously be put in place. But there is little to no agreement on what a replacement should look like—what its goals should be or what policy mechanisms it should employ—hence Trump's admission that the legislative process could take a year or more. Yet proceeding down that slow path could result in insurers bailing on the exchanges, and further destabilization of the exchanges along with disruptions in coverage, even in the absence of any concrete action. Because the law's insurance regulations would still be in place, the result would not be a return to the pre-Obamacare status quo, but be a dysfunctional and largely empty individual marketplace, one that would arguably be worse than either Obamacare or its predecessor.

It is at least possible, then, that Republicans may end up unwinding a major part of the law almost by accident—or at least through disorganization rather than any thought-out plan—by doing little more than talking about the possibility of repeal. The entire episode, meanwhile, is a reminder of both the health law's fundamental political and policy weaknesses, as well as the hollowness of the GOP's opposition, and the party's utter unpreparedness to follow through on its own promises.

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  1. This is going to end up being the biggest poison pill of, maybe, ever.

  2. ObamaCare is failing, just as it was meant to do. Only progs thought they’d be in power when it failed so they could ‘save’ it with nationalization / single payer

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  3. …drive away both insurers and customers from its exchanges, leaving only an empty husk of a program in its place.


    1. “As a cost saving measure, all ACA benefits now have been reduced to a single injection of Z-virus. Don’t worry, you will keep getting supplied with fresh Republican flesh, and you will still be able to vote Democratic on our new, simplified ballots.”

  4. The entire episode, meanwhile, is a reminder of both the health law’s fundamental political and policy weaknesses, as well as the hollowness of the GOP’s opposition, and the party’s utter unpreparedness to follow through on its own promises.

    The hollowness of their opposition? These are principled people, I’ll have you know. They were opposed to Obamacare’s conception, but once the thing was born they couldn’t very well abort it, could they? I mean, sure, it was the product of both rape of the taxpayer and incest between the lobbyists and the legislators and it certainly posed a threat to everybody’s health, plus it came out horribly disfigured and without a chance of survival without a constant stream of expensive care, but the GOP has a firm stance on never terminating any program once it’s drawn its first breath. Just like the Democrats.

  5. The new thing for the media is to point out all the other things that the ACA does besides marketplaces and subsidies. This is a consistent trend with NPR and in newspapers too.

    How else will anyone remember that, before Obamacare, coyotes used to roam the streets at night and carry toddlers away?

    1. I was told by a prog that before Obamacare passed, 45 million people a year died from lack of health insurance. And the person was dead serious. I told him that if that’s true, just repeal it and in less than 10 years we won’t have an issue, everyone will be dead.

      1. Think of all those carbon credits…

        1. Only if you sequester the corpses. Otherwise, they’re only carbon neutral=no credits.

          1. Or just recycle, I suggest this because _I’m a humanitarian_.

    2. Slavery gave all the slaves ‘free’ food and housing!

  6. The mainstream media has been ramping up the anecdotal stories of people who will be hurt if Obamacare is repealed.

    Funny I don’t recall them ever reporting on the stories of all the people who were already in the the individual insurance market prior to Obamacare who got screwed with huge premium increases for new Obamacare policies that had far higher deductibles than what they had before. Those who liked their insurance were most certainly NOT able to keep it.

    I recall the reaction of liberal commentators in various forums when that first became abundantly clear. They proclaimed the prior less expensive polices to be “substandard” and those who preferred them were just too stupid to recognize them as such.

    1. Kind of how the uninsured became free riders at some point.

      1. … and magically ceased to be free riders when they got Medicaid or heavily subsidized insurance coverage. Apparently paying for your ER visits is a bridge too far, but paying for all of your healthcare is an essential societal prerogative.

        1. Yes I recall the liberal spin and blather about how the folks going to the ER were shifting costs on the rest of us and Obamacare was going to “fix” that.

          Of course Obamacare greatly increased cost shifting instead of “fixing” cost shifting. That was inherent in the plan and they blowing smoke trying to obfuscate it.

      2. Indeed. We all know that emergency room care is the very best health care available. That’s why from the rich to the proletariat, everyone lines up to get it.

        1. Hold up a Dr. at gunpoint and force them to provide the service for free, problem solved.

    2. Tone of the anecdotes changed quickly contrasting before and after ACA was passed also.

      Trying to get ACA passed, all one heard about was Grandma eating dog food because of her scripps, cue violins, etc.

      After ACA passed, it was all about get-the-nuns and Sandra Fluke’s ‘rights.’

    3. Everyone that got screwed by this law are just a bunch of bitter clingers, duh!

      1. Yes, bitterly clinging to the hope of supporting a family of 5 on one paycheck.

      2. And apparently, there are enough bitter clingers to have decimated the Democrats to their lowest level in 100 years.

  7. If it is dying anyway then just let it die – you conservative idiots.

    The GOP has never shown they can fix anything.

    1. Well, it’s the law, so it won’t just die.

  8. Good.

    Kill it. Kill it with fire.

    1. Nuke it from fucking space.

      1. Hold on a second. This installation has a substantial dollar value attached to it. This is an emotional moment for all of us. I know that. But let’s not make snap judgments, please.

  9. My wife is working on my taxes today. Turns out that for the third year in a row, my net pay has gone down due to increases in insurance premiums. This year to the tune of $5k, and about $10k total over three years. I know I’m not alone in this. The ACA cannot die fast enough. Unfortunately the only hope we have rests in the dumb ass Republicans, who didn’t do a damn thing about health care reform when they had both the House and Senate under GWB.


    1. You’re definitely not alone. My net has decreased over the last 3 year also, for exactly the same reason. And the deductibles are now so high it’s only worth using for catastrophic reasons. For anyone not going to use more than a couple thousand dollars worth of healthcare, it’s not worth anything. The middle class are basically paying for something they can’t even use.

    2. We have to replace it with something utterly retarded.

    3. At least you get to keep your insurance policy. As an independent contractor, I’m apparently uninsurable as all but one insurance company has fled my state. I’ve been dropped at the end of each of the last three years.

      I used $125 of my $6,000 deductible last year. My new policy is just under $600 a month. I suppose if I don’t like their price I can go with a different insur– oh wait that’s right.

      Well I guess I’ll just take my chances and go without– Oops, yeah, can’t do that either…

  10. The GOP really is the stupid party. This thing was going down on its own, and the Dems had no credible argument that the GOP was in any way responsible for it. And now the GOP has managed to bear hug it just as it falls off the cliff. The Dems will now be able to convince a significant fraction of the population that the ACA was just fine until Trump and the GOP decided to dismantle it, and that all the bad fallout is their fault.

  11. I don’t care how it dies, as long as it dies.

  12. The reason it could take that long is that the legislative process is not conducive to swift movement, especially on something as complex as health care policy.

    Huh? How did it get passed so quickly?

    1. It didn’t. They started on it right after inauguration in Jan. 2009 and it didn’t get signed until March 2010. And the outlines of the ACA were a significant part of the Dem. primary process during 2007 and 2008.

      1. To be fair, the ACA was written more by Democrats in Congress than by President Obama. Obama didn’t want to fall into the same trap as Clinton did with Hillarycare — and it shows.

        1. That’s true. But the Dems in Congress started their work on it in Jan. 2009. The administration had a bunch of get-togethers on the issue in early 2009 as well. But even then, nothing that was being proposed in early 2009 was new. They had been hashing it out in campaign etc. for years before. They were debating the more important details at that point- mandate, public option, etc. The GOP hasn’t even gotten to the point of proposing a broad framework from which they can start debating details.

  13. Lots and lots of words here — I guess the very simple answer of the federal government getting the ever-loving pus-spewing hell out of my personal healthcare isn’t even in the same galaxy as all this BS?

  14. Prog dissonance:

    1. We need Obamacare because of all the moochers in ER passing costs onto others and getting a free ride since they aren’t covered by health insurance

    2. Obamacare is great because of the expanded medicaid and people getting massive subsidies so they are covered!

    Item 2 would be passing costs onto others namely the middle class

  15. Just fucking repeal. Screw ‘replace’, screw ‘repair’, screw ‘reform’. Repeal it, in toto, with a freaking one-line bill, before the end of the month, at the cost of the passive legislative filibuster if necessary.

    Anything else rewards the Democrats for shoving the thing through on the party-line vote with a transient majority, and will result in another mess like this the next chance they have to do something like this. Which may be as soon as four years from now.

  16. Query: Could another reason for the decline in exchange enrollment be increasing employment, i.e. more people getting health insurance through job benefit?

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  18. I know the market in the Southwest. I work in the industry. I know people that make decisions. If the rest of America is trending anything like it is down here, the ACA is dead even if know one touches ever touches it again and there is really no way to save it without getting rid of the mandate for insurance companies to take preexisting conditions (which is the most popular part, and I’m not sure if can be removed by reconciliation in any event, and trump says he likes, and a fuckton of people already got in on).

    BCBS is about the only BUCHA still playing in a most of the southwest, and they will be gone soon. They had to spike their rates massively to stay in it all this year.

    Which makes the republicans willingness to get their name and stank all over the ACA at this late date the height of insanity.

    They won’t be hailed as the good samaritan: they’ll be viewed as the greedy relative who pulled the plug. They should run away from this thing like it’s a fire at a chinese fireworks factory.

    Bud they are just so bad at all of this.

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