If James Comey, the FBI director, hadn’t tipped the scales in the campaign’s final days with that grotesquely misleading letter, right now an incoming Clinton administration would be celebrating some very good news. Because health reform, President Barack Obama’s signature achievement, is stabilizing after a bumpy year.
This means that the huge gains achieved so far — tens of millions of newly insured Americans and dramatic reductions in the number of people skipping treatment or facing financial hardship because of cost — look as if they’re here to stay.
Or, they would be here to stay if the man who squeaked into power thanks to Comey and Vladimir Putin wasn’t determined to betray his supporters, and snatch away the health care they need.
To appreciate the good news about Obamacare, you need to understand where the earlier bad news came from. Premiums on the exchanges, the insurance marketplaces created by the Affordable Care Act, did indeed rise sharply this year, because insurers were losing money. But this wasn’t because of a surge in overall medical costs, which have risen much more slowly since the act was passed than they did before. It reflected, instead, the mix of people signing up: fewer healthy, low-cost people than expected, more people with chronic health issues.
The question was whether this was a one-time adjustment or the start of a “death spiral,” in which higher premiums would drive healthy Americans out of the market, further worsening the mix, leading to even higher premiums, and so on.
The answer is that it looks like a one-shot incident. Despite higher premiums, enrollments in the exchanges are running ahead of their levels a year ago; no death spiral here. Meanwhile, analysts are reporting substantial financial improvement for insurers: The premium hikes are doing the job, ending their losses.
In other words, Obamacare hit a bump in the road, but appears to be back on track.
But will it be killed anyway?
In a way, Democrats should hope that Republicans follow through on their promises to repeal health reform. After all, they don’t have a replacement, and never will. They’ve spent seven years promising something very different from yet better than Obamacare, but keep failing to deliver, because they can’t; the logic of broad coverage, especially for those with pre-existing conditions, requires either an Obamacare-like system or single-payer, which Republicans like even less. That won’t change.
As a result, repeal would have devastating effects, with people who voted Trump among the biggest losers. Independent estimates suggest that Republican plans would cause 30 million Americans to lose coverage, with about half the losers coming from the Trump-supporting white working class. At least some of those Trump supporters would probably conclude that they were the victims of a political scam — which they were.
Republican congressional leaders like Paul Ryan nonetheless seem eager to push ahead with repeal. In fact, they seem to be in a great rush, probably because they’re afraid that if they don’t unravel health reform in the very first weeks of the Trump era, rank-and-file members of Congress will start hearing from constituents who really, really don’t want to lose their insurance.
Why do the Republicans hate health reform? Some of the answer is that Obamacare was paid for in part with taxes on the wealthy, who will reap a huge windfall if it’s repealed, even as many middle-income families face tax hikes.
More broadly, Obamacare must die precisely because it’s working, showing that government action really can improve people’s lives; a truth they don’t want anyone to know.
How will Republicans try to contain the political fallout if they go ahead with repeal, and tens of millions lose access to health care? No doubt they'll try to distract the public, and the all-too-compliant news media, with shiny objects of various kinds.
But surely a central aspect of their damage control will be an attempt to push a false narrative about Obamacare’s past. Health reform, they'll claim, was always a failure, and it was already collapsing on the eve of the GOP takeover. When the number of uninsured Americans skyrockets on their watch, they'll claim that it’s not their fault; like everything, it’s the fault of liberal elites.
So let’s refute that narrative in advance. Obamacare has, in fact, been a big success — imperfect, yes, but it has greatly improved (and saved) many lives. All indications are that this success is sustainable, that the teething problems of health reform weren’t fatal and were well on their way to being solved at the end of 2016.
If, as seems all too likely, a health care debacle is imminent, blame must be placed where it belongs: on Donald Trump and the people who put him over the top.
Paul Krugman, winner of the Nobel Prize in economics, is a New York Times columnist.