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Episode: 2470
Title: HPR2470: Obamacare Update At The End Of 2017
Source: https://hub.hackerpublicradio.org/ccdn.php?filename=/eps/hpr2470/hpr2470.mp3
Transcribed: 2025-10-19 03:45:35
---
This is HPR episode 2470 entitled Oba Makarab, made at the end of 2017.
It is hosted by AYUKA and in about 13 minutes long and carry a clean flag.
The summary is where in US healthcare policy as we head into 2018.
This episode of HPR is brought to you by archive.org.
Support universal access to all knowledge by heading over to archive.org forward slash donate.
Hello, this is AYUKA, welcoming you to another exciting episode of Hacker Public Radio.
And I'm going to give a kind of a year end look at what is happening with healthcare
in the United States, because there's been a few things since I ended my previous look.
So since we did our analysis of how Obamacare works, there has been a lot of activity in
Washington, D.C., but in fact relatively little change.
Now literally from the day the bill was passed, the Republican Party in the United States
made it their top priority to repeal it and said so at every opportunity.
Of course as long as Obamacare was president, they could not do it since they never had
enough votes to override his veto.
They passed repeal bills annually, if not more often, but none of them went anywhere.
But when the Republican candidate Donald Trump won a surprise victory in the 2016 election,
there was no longer anything to stop them.
Trump had run on among other things, promising to repeal Obamacare.
And from the moment he was inaugurated, he proclaimed his signature pen was ready as soon
as a bill was passed.
And that is when things got tricky for the Republicans.
As you may recall from our previous analysis, Obamacare was a finely balanced combination
of measures that had at least something that each party wanted.
And as the Republicans started trying to craft measures to repeal the legislation, opponents
of all kinds came out of the woodwork.
It turned out insurance companies favored keeping it, the majority of doctors favored
keeping it, the people who were insured favored keeping it, and even some Republicans turned
out to have reservations about repeal.
So let's look at these.
First of all, insurance companies.
The insurance companies had done reasonably well out of Obamacare since it provided an
increased number of people they could insure and make money from.
They had made all of the adjustments they needed to make by 2017, and now saw the Obamacare
landscape as a known environment that they could make money in.
Repeal would take them in the realm of the unknown because it would inevitably mean something
different from just returning to the status quo ante of 2008.
Doctors.
Okay, majority of physicians wanted to keep Obamacare because they'd increase their
pool of customers.
The American Medical Association came out in strong opposition to the repeal of Obamacare.
Hospitals.
They opposed the repeal because it would make their financing more fragile, among other
things, hospitals liked Obamacare because it significantly reduced their cost for what
is called uncompensated care.
That is, patients who receive care but cannot pay for it.
They did this in two ways.
First, more people with insurance policies purchased through the exchanges, meant in
essence more paying customers.
Second, Obamacare included a provision for individual states to expand Medicaid, which
is the program for providing health care to people to poor to afford coverage on their
own.
This Medicaid expansion was very significant since it provided coverage to the very people
most likely to receive uncompensated care in the absence of this program.
And patients.
The majority of patients liked Obamacare by the time we got to 2017 and that made repealing
it more difficult.
This increase in support was slow but consistent from the initial passage in 2010 when on balance
more opposed than supported it to 2017 where that was reversed.
I think the best explanation for this is that as people saw how the program worked, they
could see the benefit and learned that some of the overblown rhetoric like charges about
death panels was not really true.
Finally, the state governments.
Many states had expanded Medicaid under Obamacare and did not want to give up that benefit.
This even included a number of states under Republican government, such as the state
of Ohio, that essentially broke with their Republican colleagues over this.
This is something that would complicate the repeal process all year.
So with all of this opposition, why was the repeal being pursued at all?
Normally, you would expect a measure this unpopular to be quietly dropped, but that
is not what happened at all.
It was pursued with an intensity that was really quite remarkable.
But it would appear that several factors were at play here.
First the Republican Party had made this the centerpiece of their platform for eight years.
They had elevated this to the status of a moral crusade against evil and sold that idea
to their constituents and were now expected to deliver to their base.
One useful way to look at the election of 2016 was that it was a reaction against politicians
who say one thing to get elected, but do something different once they are in office.
Because the Republican politicians had made this so central to their election platform,
they felt compelled to deliver.
As Dave Bratt, a Republican member of Congress said, and I quote,
if we don't get health care, none of us are coming back.
He said in a brief interview,
we said, for seven years, you're going to repeal Obamacare.
It's nowhere near repealed.
Now, I've got a number of quotes in this, and there will be links in the show notes to news articles.
You can see where I got all of this from.
You can look up the articles if you're interested.
Now, the next reason has to do with donors who fund the Republican Party.
They had made it clear that either the Republicans delivered,
or they could forget getting campaign contributions.
For instance, a major Koch network donor in Texas named Doug Deeson said,
get Obamacare repealed and replaced, get tax reform passed.
Deeson said in a pointed message to GOP leaders, you control the Senate,
you control the House, you have the presidency.
There is no reason you can't get this done.
Get it done and we'll open it back up.
And the it he's referring to is the checkbook.
So they will open the checkbook once the Republicans deliver.
So they hit their marching orders and they tried.
First, the House of Representatives pulled a bill together in the spring.
Paul Ryan pulled it from the floor on March 24th because he did not have the votes.
The bill was being opposed by centrists who said it went too far
and by conservatives who said it did not go far enough.
Then they came back to it and a couple of months later,
they managed to pass a bill and send it to the Senate.
Now, that opened a different can of worms.
Since the Republicans in the Senate had a very narrow 52 to 48 majority
and would face a democratic filibuster.
So they had to use a special parliamentary provision called reconciliation
that would let them pass the measure on a strict majority of just 51 votes
instead of the 60 votes that's required to defeat a filibuster.
Now, that was possible but only under restrictive circumstances
that meant that the bill they got from the House would not work.
So they started on their own bill designed to repeal and replace
but that got shot down when several Republican senators said they opposed the measure.
Then they came back again and said, all right, you don't like repeal and replace.
Let's just do a straight repeal.
And then that failed on July 28th when three senators opposed the bill.
Then they came back to it again in September with one more effort.
And again, three senators opposed it and by now they had run out of time.
Reconciliation had to be completed by September 30th and they just ran out of calendar.
Then in the tax bill that they went to after this,
they did the one thing that actually had some popularity
and now it's to eliminate the individual mandate that said people had to either purchase insurance or pay a fine.
The US Supreme Court had ruled that this was a tax
and that made it practical to repeal and a tax measure.
So that aspect of Obamacare has been removed.
So where are we at the end of 2017?
Well, first and perhaps most important,
Obamacare is still more popular than you might think from all of the Republican rhetoric.
The Trump administration cut the enrollment period in half,
cut the publicity budget by 90%
and still enrollments were very healthy.
8.8 million people signed up through the federal marketplace
and that was only 4% below the 2016 number
when they had twice as much time and a lot more publicity.
But how will the repeal of the individual mandate affect the marketplace?
Well, the fear is that we could have a real problem of adverse selection.
Younger, healthier people might opt to go without insurance
and then as soon as they have a serious injury or illness, sign up for it.
The Obamacare provision that prevents companies from denying coverage
for pre-existing conditions is still the law
and this could lead to premiums that skyrocket.
Paradoxically, repealing this measure has caused the federal government's healthcare bill to go up
and the reason is as premiums increase,
the subsidies paid on behalf of low income people also increase.
So the government ends up paying more.
You know, there's no free lunch in any of this stuff.
Someone somewhere is paying the bills.
The argument is really over who it will be.
Now, and this is my personal view, it is shared by many people,
is that the Republicans are, despite what they think,
pushing us in the direction of a completely government-funded healthcare system,
though to what degree it resembles any of the other systems used in other countries
is yet to be determined.
It probably won't be exactly like any of them.
But then, you know, healthcare in England and healthcare in France and healthcare in Canada
are three different systems, even though all of them are basically government-funded.
So why do I say that we're being pushed this way?
Well, I'm a quote from Paul Waldman who said,
but those with low incomes will be getting free or low-cost insurance courtesy of the government,
which everyone else will continue to notice.
We wind up with a system made up of one,
people who get coverage from the government and are happy with it.
Two, people who get coverage from their employers and like the coverage,
but don't like the cost.
Three, a small number of people who pay the full cost of private coverage,
which is increasingly unaffordable.
And four, people who are uninsured and wish they could get on a government plan
such as Medicare or Medicaid.
So I think in the final analysis, Obamacare was the most moderate plan
the Republicans could hope to get, and they rejected it.
It was devised by Republicans initially,
although they frequently deny that, but you know, study your history.
This was the Heritage Foundation plan from 1993 initially.
It was implemented by a Republican governor,
and it was the alternative to anything more radical.
But I think we will see the more radical solutions going forward.
Bernie Sanders put down a marker in the 2016 race,
and you will certainly see Democratic candidates putting forth plans
that move us to single payer as they jockey for position in the 2020 race.
And so this is a hookah signing off,
and as always reminding you to support FreeSoftware.
Bye, bye.
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