Obamacare’s Original Sin

We can resist Republican efforts to repeal Obamacare without providing cover for the law’s deep ideological flaws.

By Adam Gaffney
Jacobin, Feb. 15, 2017

Republicans are struggling to find the proper pitch for their attack on the Affordable Care Act (ACA). “Repeal and replace” — the tried and true formulation — may be mutating into something mellower, albeit more vacuous. “Americans want the ACA repealed and repaired,” Republican strategist Frank Luntz recently told the Associated Press, using the new nomenclature.

Should this right-wing retreat — or rather, recalibration — be construed as a victory, however minor? Probably not, for two reasons.

First, whatever the tweak in marketing, the crux of the matter hasn’t changed: Republicans seem poised to engineer an enormous increase in uninsurance in the coming years (at the cost of countless lives).

And second, “repeal and repair” will double down on the worst elements of the status quo. Whatever term they use, Republicans never intended to remove the central pillar of the US health care system (and the ACA): private health insurance.

As two of my colleagues, David Himmelstein and Steffie Woolhandler, put it shortly after Trump’s election:

We suspect that the [Republican’s] likeliest replacement [for the ACA] is a meaner (and rebranded) facsimile of the ACA that retains its main structural element — using tax dollars to subsidize private insurance — while imposing new burdens on the poor and sick.

The 2016 health care reform framework of Paul Ryan and the House Republicans, for instance, would provide tax credits to help individuals and families purchase private plans “through multiple portals, including private exchanges.” Ryan’s tax credit scheme amounts to a more regressive version of the ACA’s subsidies for plans bought on the “marketplace” (also known as “exchange” or “Obamacare” plans).

In other words, we should expect the looming GOP health care overhaul to be more right-wing regression than reactionary revolution.

This relative continuity highlights an important point: one of the ACA’s key mechanisms for moving us toward universal health care — publicly subsidized, privately sold “marketplace” plans — was never going to achieve its goal.

Millions now rely on these plans, and we should defend them until we can win something better. But we also shouldn’t entertain any illusions: the ACA marketplaces rest on a flawed health care ideology that tellingly attracts many adherents on the Right, including Ryan.

What are the roots of this ideology — sometimes known as “managed competition” — and how can we move beyond it?

full article:

Adam Gaffney is an instructor in medicine at Harvard Medical School, a pulmonary and critical care doctor at the Cambridge Health Alliance, and a national board member of Physicians for a National Health Program. He blogs at