I do actually care about the deficit, so this isn’t hard. If my budget hawk hat were the only one I wore, I’d think this way:
The ACA has provisions that are clearly in the spending category (Medicaid expansion, exchange subsidies), provisions that are clearly in the savings category (Medicare cuts), provisions that are clearly in the revenue category (taxes), and provisions that are in the experimental category (ACOs).
Thus, if I were to make a budget-based argument for repeal, I’d advocate a partial one. Kill the spending, keep the savings, keep the revenue, and probably keep the experimental. The experiments could have costs, but it is hard to argue that we don’t need to try new Medicare/Medicaid financing approaches. Maybe not all of the savings will materialize, but should we not try to save something in an otherwise fiscally unsustainable patchwork of federal/state health systems?
Why does full repeal make sense? It only does if one has more than just a budget hat on. Same goes for keeping the law, or advocating for its passage in the first place. But if one has other goals in mind, beyond the budgetary, why not state them? What are they? How do you craft a bill that can both pass and fulfill them?
When I wear my budget hawk hat, I find myself hoping the cost controls in the ACA work and also wishing they were stronger, different, and occurred sooner. For all that, I support the ACA because of its insurance market reforms. That is, I’ve got another hat.
Pro- or anti-ACA, what hats do you wear? Which of them justifies full support or full repeal, if any? Which don’t?
UPDATE: This comment is not worth a second post, so I’ll append it here. I do wonder who is really listening to the ACA cost debate and whose minds could possibly be changed based on it. (We did already go through all of this before.) Moreover, after the House repeal vote attacks, will be more targeted: tweak this, undo that, not fund this other thing. I get the feeling the uber-wonks are yelling at each other and nobody else is really listening, let alone comprehending.