Replacing Obamacare: The Strategies and Options

This is the fourth and final article in a series on the rollout of Obamacare, and how the law will change our health care system. Each of the past two weeks, we have published two articles: one on the changes in medicine and medical care and one on changes in the insurance industry. We hope this series of articles will help you make better decisions when it comes to your health care and how you buy insurance.


The Republicans in the Senate and House are now involved in the early stages of what appears to be a major internal food fight over how to leverage the GOP’s opposition to Obamacare with the need to pass a continuing resolution to keep government financed and, soon thereafter, to raise the nation’s debt ceiling. Some conservatives in Congress, encouraged by a few talk radio personalities, are supporting a strategy of seeking to defund Obamacare as their price for allowing the government to continue its business in other areas and to continue to borrow. For fiscal 2013, the federal deficit will be about $800 billion, a reduction from the trillion-dollar plus deficits of the prior Obama years due to additional tax revenues from the year-end 2012 deal on the “Bush tax cuts,” Obamacare tax increases, and some modest spending cuts due to the sequester.

Other Republicans wish to delay the implementation of Obamacare until 2014, focusing in particular on the individual mandate. Since the administration unilaterally delayed for a year the employer mandate (without asking Congress to bless this action), some Republicans seek to formally authorize the delay for both the employer and individual mandates.

Republicans in the House have passed an Obamacare repeal measure over three dozen times since they won control of the House in the 2010 midterm elections. Naturally, this effort never went anywhere in the Democratic-controlled Senate. Even if some Republican Senate candidates had not self-destructed in 2010 and 2012 in winnable races and the GOP had won control of that body, an Obamacare repeal measure that went to the president would have been vetoed.

The president is reeling from a perception that he has been a weak leader and badly mishandled the Syrian chemical weapons “red line” he had set, even if most Americans are happy that we are not engaged in a new military effort. Also, the economy is still struggling, and Obamacare is increasingly unpopular with the opening of the state exchanges now less than a week away.

A constant refrain from left-of-center supporters of the new health care law has been that the Republicans want to get rid of Obamacare, but have never offered anything substantive to replace it. Whereas Obamacare, at over 2,000 pages and with well over 10,000 pages of supporting regulatory language so far, is presumably just what the doctor ordered.

However, the Republicans have in fact offered substantive proposals, and this week House Republicans again offered a health care bill to replace Obamacare. Of course, it does not address every aspect of the legislation the Democrats rammed through in 2010, and should not be viewed as a provision-for-provision substitute.

The Affordable Care Act expanded Medicaid coverage up to 138% of the poverty level for individuals and families. Justice Roberts’ decision affirming the legality of the individual mandate also allowed states to decline to expand Medicaid without risk to their current level of federal funding for the existing Medicaid program. The other major access expansion came through employer and individual mandates. In each case, penalties would be assessed for employers of a certain size not providing health insurance to their full-time employees, and for individuals who did not purchase an individual insurance policy in the new exchanges. Given the “free shot” to enact a health care reform bill relying solely on Democrat votes, the Obamacare bill was also larded with thousands of pages and hundred of provisions regulating just about every aspect of the industry and the delivery system.

The new GOP alternative is a different animal entirely from Obamacare. It is designed to support free market competition rather than regulate private market activities. One way it does this is by allowing cross-state competition in the private insurance market. Obamacare limits the type of insurance plans that can be provided in the state exchanges in terms of the  percentages of plan cost that must be provided in coverage benefits, and mandates that all coverage in every state include a fairly comprehensive package of health care services in all plans offered on exchanges. True insurance competition in individual states would allow much greater variability in plan offerings. It has been demonstrated for many years that when individuals or employees have “skin in the game" -- meaning their own dollars are at risk -- they are more cautious about health care spending. They also respond to financial incentives for promoting better health (smoking cessation, exercise, weight management). High-deductible, catastrophic policies are attractive to many younger people and to those in good general health.