Repeal and the reform coalition

An expansion of something I expressed in several tweets earlier today:

Presume for the moment that Republicans retain the House and take the Senate and White House in 2012. Can they repeal health reform? Legislatively, it appears so. And, by the way, with a simple majority they could rewrite the filibuster rules so that reconciliation isn’t the only way.

But what about politically? That question isn’t just about the electorate or the GOP base, but about interest groups. Will the coalition of interest groups that supported the ACA oppose repeal? I’m not convinced they will (in entirety), especially given what austerity may do to hospitals. Slashing payments doesn’t win political favors or garner support for one’s reformed regime.

This austerity/health reform connection seems to be underappreciated. Medicare succeeded initially in part due to generous provider payments. Thus, cost control and health reform are (at least initially) at odds politically. That’s why the only way to succeed at cost control is to build the cost control structures first but don’t actually add the cost control teeth until later, and then only slowly.

Quoting myself, “You have to make eventual losers feel like winners.” I cannot imagine another politically viable approach. So, the question becomes, how does the ACA make key interest groups feel, not in 2010, not now, but in 2013? There is no guarantee they’ll feel as they did when they supported the legislation. Times change, and so do positions. What the supercommittee and Congress do over the next year will play a role in how those positions shift. Certainly what might replace the ACA, should it be repealed, matters too, particularly to the insurance industry.

In any case, I’m less confident than others are that repeal through legislation (as opposed to by the courts) is impossible or even improbable. A lot depends on how deficits are cut. A lot depends on the 2012 election too. If that goes big for the Republicans, I think there is a good chance health reform will be at risk.

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