House Speaker Mike Johnson has a clear record on repealing the ACA

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The rise of Mike Johnson president of the House last week was so quick and so improbable that only now is his record starting to attract attention.

Hoo boy, is there a lot to consider.

The Louisiana Republican, now serving his fourth term, has led efforts to cancel the 2020 elections. He voted for a national ban on abortion. He called for criminalize gay sex.

But wait, there’s more. Johnson also supported repealing the Affordable Care Act – a.k.a. Obamacare.

You might think it doesn’t really matter. After all, Republicans don’t control the Senate or the White House, and these days they don’t seem particularly interested in health care anyway. During the great 2019-2020 legislative fight around President Joe Biden’s proposal to reduce prescriptions medication costs, the most remarkable thing about the Republican opposition was its absence. They barely said a word.

The same goes for the Affordable Care Act, which is quite different from the many years when Republicans talked incessantly about repealing it. They finally got their chance in 2017, when Donald Trump was president and Johnson, then new to Congress, I voted yes. The effort failed, but not before causing a huge political reaction it helped Democrats regain control of the House of Representatives – and, two years later, the presidency and the Senate as well.

These days, it’s news when a Republican says the word “Obamacare.”

But that doesn’t mean Republicans have made peace with the 2010 health law, or that they’ve abandoned their ideas of replacing it with conservative alternatives. And you won’t find better proof than in a 2019 Republican Study Committee Proposalwhich Johnson was leading at the time.

The word “repeal” appears only a few times, always in a narrow context. But the repeal legislation is all there. Three in particular stand out.

About half of the 58-page document examines the high cost of American health care, its effects on individual Americans and the many ways Republicans say the Affordable Care Act is responsible for these problems. One of the biggest concerns is the law’s regulations prohibiting insurers from denying coverage or charging higher premiums to people with pre-existing conditions, and requiring all policies to include basic “essential” benefits.

The report says these regulations have made insurance more expensive, which is true in the sense that it means insurers today can’t turn away people with serious medical needs or stop paying their bills. It costs money. And while the GOP report acknowledges that the Affordable Care Act’s tax credits offset these higher costs for most people, it says it’s an inefficient way to obtain social coverage and warns that it still leaves many Americans with high bills.

Again, there is a lot of truth in both cases. But the Republican alternative backed by Johnson and his allies would roll back existing regulations, preserving coverage guarantees only for people who maintain continuous coverage and ending federal requirements on essential benefits. And it would end the current subsidy system, replacing it with a combination of tax changes and support for new savings accounts.

It’s hard to be specific about what effects any of this would have today, because the GOP report doesn’t contain a detailed budget. But, from a conceptual point of view, that’s pretty much what the Republicans were proposing with their repeal bills in 2017: fewer rules governing what insurance must cover and less government assistance to help people get insurance.

Virtually each independent analysis has the time concluded that healthy people could have access to cheaper insurance premiums, but only because people in poorer health would find themselves facing higher premiums or out-of-pocket costs – or even being unable to get coverage at all.

To put it more simply, it was a way of shift medical care costs on people who need it. There is every reason to believe that the proposal released by Johnson and his allies in 2019 would do the same thing.

The GOP report has an entire section on what it calls “the failure of the ACA’s Medicaid expansion.” That’s a reference to arguably the most significant change in the law: federal funding that allows states to expand Medicaid, the half-century-old insurance program for low-income Americans, so that anyone with an income below or just above the poverty line is eligible. Previously, most states limited registration to certain groups of people, such as children and pregnant women.

This expansion, which all but ten states have now adopted, is the main reason the number of Americans without insurance has fallen to historic lows. Much academic research shows that Medicaid expansion has made a real difference in people’s lives, improving their financial, emotional, and physical well-being. But of course, it also costs money, with the federal share alone topping a hundred billion dollars each year.

And that’s not the kind of spending that Republicans — or Johnson — have ever supported for this type of program.

The GOP document envisions ending the expansion in two stages. This would begin with a moratorium on the expansion of new states, at a time when resistance in Refractory States has softened. (The expansion even gained some momentum Mississippi.) Then the federal government would reduce the extra money it provides to states for expansion, until there is no extra money at all.

Analysis of similar provisions in the 2017 repeal proposals predicted that a rollback would cause millions of people to lose their insurance coverage. The GOP document does not directly acknowledge this. It’s telling that the word “uninsured” only appears a half-dozen times.

The GOP document doesn’t simply envision rolling back Obamacare’s changes to Medicaid. It also calls for a fundamental change in the structure of the program: Johnson and the Republicans want to move Medicaid from an open-ended entitlement, meaning funding increases when demand for Medicaid coverage increases, to a fixed, predefined amount. called “per capita”. cap.”

Yes, that was also a feature of the 2017 proposal and, again, analyzes found that it would result in less money for Medicaid over time. Of course, that’s precisely the goal of the conservative view: spending less money on Medicaid. But it is already widely accepted that Medicaid is underfunded. Cut funding for the program further, and that will mean fewer services covered or fewer people eligible for coverage.

It’s simple, mathematical. And it’s almost certain to affect the most vulnerable groups on Medicaid, even though they’re the ones Republicans say they want to protect. If you want to know what that would mean in real life, consider an Ohio student with cerebral palsy who I wrote about in 2017 — and what the Medicaid cuts under discussion might have meant for him then.

The Republican Party document produced by Johnson and his allies has other elements as well – some previously unpublished, others familiar to anyone who remembers the battle over repeal. But the fundamentals have not changed: “Republicans have been very quiet publicly lately on repealing the ACA, but this proposal would have effects every bit as sweeping as the repeal-and-replace plans debated by Congress in 2017.” Larry LevittKFF executive vice president for health, told me via email.

The big question at this point is whether Republicans would actually try repeal again, given the political contingencies. Polls show a majority of Americans now support the Affordable Care Act and, for all its flaws and inadequacies, it has become part of the status quo – people have come to to wait for its protections – in a way that has historically made the programs difficult to dislodge. (I wrote a book about this transformation if you are interested.)

Johnson, for his part, hasn’t said it’s a priority — or even whether he stands by the proposal he and his allies put forward in 2019. When I asked his office about it Friday, Corrine Day , its communications director, responded: “The President will work within the Conference to achieve consensus on a health care plan. The conference recognizes the need to fix our broken system and will examine solutions to increase the quality of care and reduce costs.

But the lack of political visibility of health care in general and Obamacare in particular can be double-edged. Precisely because Republicans like Johnson no longer talk about repeal, describing their initiatives as efforts to “personalize” health care and “protect the vulnerable,” few seem aware of what they are doing. actually offer. This could make it easier to implement their program, or at least a large part of it.