(Katherine Frey/The Washington Post)

M.J. Lee of CNN has flagged a great moment at a town hall meeting with GOP Rep. Diane Black that has gone viral because it shows a constituent making an impassioned case for, of all things, the Affordable Care Act’s individual mandate. As some immediately pointed out, Democrats could learn from this kind of messaging.

But the moment is notable for another reason, too: The answer offered by Rep. Black shows how much the debate over the health care law has shifted, in favor of the health law.

You should watch the whole exchange, which took place in Murfreesboro, Tennessee. The constituent, Jessi Bohon, a schoolteacher, argues that one of the ideas that Republicans have put forth for covering people with preexisting conditions — high risk polls — is unworkable. In the course of so doing, she makes a moral and religious argument for the mandate:

She says:

“It’s my understanding that the ACA mandate requires everybody to have insurance, because the healthy people pull up the sick people. As a Christian, my whole philosophy in life is to pull up the unfortunate. The individual mandate, that’s what it does. The healthy people pull up the sick.

“If we take those people, and we put them in high risk insurance pools, they’re costlier, and there’s less coverage for them. That’s the way it’s been in the past, and that’s the way it will be again. So we are effectively punishing our sickest people.”

Bohon goes on to call for expanded Medicaid to cover everybody.

The individual mandate is designed to bring younger, healthier people into the insurance pool, in order to make it possible to cover everyone with preexisting conditions, without rendering the risk pool too sick and costly to work. Subsidies are made available to those with lower incomes to buy that insurance. Republicans say they want to make sure people with preexisting conditions can get coverage, but want to repeal the mandate (and the subsidies, though they are talking about replacing them in some form).

One Republican solution to this is high risk pools. But as Ms. Bohon says, this has its drawbacks: As an extensive New York Times piece recently detailed, high risk pools attempted on the state level have driven up costs for beneficiaries and have left many people uncovered.

What’s notable here is the answer that Rep. Black gives to this constituent, which you can watch right here.

Rep. Black says that the mandate hasn’t worked, noting that the young and healthy did not get on to the exchanges. It’s true that the future of the marketplaces is anything but certain. But as Jonathan Cohn recently reported, many experts think that the talk of skyrocketing premiums and “death spirals” is vastly overblown, and that they very well may be fine over time.

Rep. Black also insists the mandate has failed by pointing out that a total of 20 million people have either paid the fine or gotten an exemption instead of getting coverage. Rep. Black then concedes that 20 million other people have gotten coverage under Obamacare, but then insists that those two blocks of 20 million cancel one another out:

“If you have 20 million people that were helped over here, but 20 million people that were hurt over here, that just said, ‘I can’t afford it,’ or ‘I don’t want it,’ or ‘it’s not going to work for me’….you don’t want to hurt one group of people to help the other. We can help both groups at the same time.”

Even if you accept this idea that one group cancels the other out, what’s really interesting is that Rep. Black says that the goal should be to help everybody. We can help both groups at the same time! Okay, how?

The Republican replacement plan is likely to cost many millions their coverage. Republicans want to take steps to make coverage more affordable (never mind for now whether their solutions would actually do that), which they will call “access” to coverage, rather than strive for a universal coverage guarantee, as Obamacare does. Republicans don’t want to spend as much money or regulate the individual market to the degree that the ACA does, and that is very likely to result in many fewer people covered, or less generous coverage, or both. That’s the GOP’s preferred philosophical approach.

But this town hall exchange shows yet again that the debate has shifted: Republicans now feel obliged to say that everybody will do better under their alternative. President Trump and his advisers have offered an even starker version of this, claiming that no one will be left without coverage who now has it.

But the problem is, absent an actual GOP alternative, we cannot compare that alternative to Obamacare, in terms of how many people would get coverage and what that coverage would look like. So we are left in a situation where Rep. Black tells her constituents that the Republican goal is to help everybody in a manner superior to Obamacare’s means of doing that, even as there is no way to evaluate whether the eventual GOP plan will actually accomplish that goal.

Indeed, this may be the real reason for “repeal and delay,” in which Republicans would repeal the law now on a delay, to give themselves time to come up with their own alternative later. If they were to vote at the same time on repeal and the GOP replacement plan, such a comparison would be possible. They would be voting to replace one with the other. But that might not be politically desirable, since that comparison might reveal that the GOP plan leaves a lot of people without coverage — something Republicans don’t want to say aloud. Instead, Rep. Black can tell her constituents that the Republican goal is to help everybody — a goal at which Obamacare has failed, naturally — while leaving the details until later.

But even under this “repeal and delay” scenario, there will presumably come a point at which, with the drop-dead moment of actual repeal looming, Republicans will vote on a replacement that probably does cover far fewer people.  That moment cannot be put off forever.

 



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