If ACA opponents gain a majority in either house of Congress, they could not only withhold needed appropriations but also bar the use of whatever funds are appropriated for ACA implementation, including the implementation of the provisions requiring individual people to buy insurance or businesses to offer it. They could bar the use of staff time for designing rules for implementation or for paying subsidies to support the purchase of insurance. They could even bar the DHHS from writing or issuing regulations or engaging in any other federal activity related to the creation of health insurance exchanges, even though the ACA provides funds for the DHHS to make grants to the states to set up those exchanges.
Perhaps the more likely — and in some ways more troubling — possibility is that the effort to repeal the bill will not succeed, but the tactic of crippling implementation will. The nation would then be left with zombie legislation, a program that lives on but works badly, consisting of poorly funded and understaffed state health exchanges that cannot bring needed improvements to the individual and small-group insurance markets, clumsily administered subsidies that lead to needless resentment and confusion, and mandates that are capriciously enforced.
This may be “more troubling” to Aaron, and anyone who is in interested in an efficient and minimally equitable health care system, but the real losers here would be the health insurance companies. Let’s assume that the GOP Congress puts riders in their appropriations bills forbidding the construction of exchanges or enforcement of the individual mandate. This means that the insurers will still have to abide by the popular provisions of the ACA: no discrimination against those with pre-existing conditions, no rescissions, no lifetime limits. (I doubt at this stage that the GOP would ban the enforcement of these provsions.). Thus, the insurers could not set rates according to health risks or do any of the other things that enrage most people in private plans — but they also would not get the guaranteed new millions of new customers that was supposed to be the compensation for it. They could, of course, just raise rates on everyone, risking an even further backlash, at this time directed against the GOP, which will be the immediate cause of it.
So you would think that the health insurance industry would be wary about such a scenario. But no: in fact they are pushing it. As the Los Angeles Times reported last week, the insurance companies are pouring money into Republican campaigns.
Obviously, the insurers aren’t stupid. They may think that they can get away with telling the Republicans to maintain the mandate while getting rid of the regulations, but that combination would surely be vetoed by President Obama. So in the short and medium run, the insurers are taking a risk that the changes in the market brought about by the refusal to set up exchanges or enforce the mandate (which undoubtedly the Obama Administration would refuse to enforce in the absence of exchanges) will not disrupt their bottom line. (So much for believing their whines about how they need rescission, lifetime limits, and discrimination to make money.). The ensuing chaos will help elect President Palin in 2012, and create an individual mandate without any regulations against them.
In other words, they seem to believe, along with Republicans, that they can screw up health policy reform and get the voters to blame the Democrats for it. Maybe they’re right.