As a majority of Americans await the inauguration of a president they didn’t vote for, even more Americans face an unclear future about their health care coverage.
President-elect Donald Trump and the GOP-controlled Congress have pledged to repeal and eventually replace the Affordable Care Act, known to most as Obamacare. In fact, in the wee hours of Thursday morning, the Senate began making moves to dismantle the ACA, voting 51-48 on a budget blueprint that would allow senators to gut the law without fear of a Democratic filibuster. However, the Republicans have two equally important and hard-to-fix problems: They’re beholden to the insurance lobbyists, who want to keep the bill; and, more importantly, President Barack Obama has rigged the game so that any change to the ACA will bring the whole health care system down.
The ACA/Obamacare political and policy battle over the last seven years is the perfect microcosm of the Obama presidency. Some people hate the policy because Obama came up with it (as this classic Jimmy Kimmel sketch shows); some people hate Obamacare on ideological grounds but love the Medicaid expansion, pre-existing-conditions rule and the extension of dependent health care until the age of 26. While millions of Americans approve of the law and have benefited from it, they aren’t as loud (or didn’t receive as much media attention) as those who hate it.
This deeply divided public mood explains why Republicans have been so craven and inconsistent with their calls to repeal or replace the law. They want to dismantle Obama’s legacy, but red states benefit most from the ACA. More importantly, despite more than 40 votes to repeal the law and four election cycles since its passage, Republicans have yet to come up with a comprehensive replacement law. Of course, there are two reasons for this, just not ones the GOP wants to admit to.
Remember the wooden-block game Jenga, which made a comeback at grown-up “board game parties“ in the early 2000s? The goal is to keep taking blocks from the bottom of the tower and putting them on top without the whole thing falling apart. If you’re careful when you pull, things just wobble; if you’re not, then the whole thing crumbles.
Republicans are realizing that Obamacare is a lot like the game Jenga. You can’t pull out the “bad blocks” of policy—like, say, the public mandate—and keep the “good ones,” like forcing insurance companies to cover people with pre-existing conditions. If you keep messing with it, eventually the whole thing is going to fall apart. Except instead of blocks on the floor, you have 20 million Americans thrown off their health insurance.
The second reason Republicans can’t figure out this repeal is that drug companies run this town. By “run,” I mean smack around and take lunch money, and by “town,” I mean Washington, D.C. Since the passage of the ACA, insurance-company profits have skyrocketed, as has their lobbying power and ability to pump cash into policy-friendly candidates. In order to distract critical members of Congress and the press, insurance companies are employing “nonprofits” and think tanks to find a new bad guy: the drug industry.
Now that everyone is forced into coverage, health care companies want to squeeze every dime out of the consumer. This is often done through “formularies,” which are lists of drugs that companies will and will not cover. Who determines if a drug is covered? Why, advisory nonprofits funded by health-insurance companies, of course.
It’s much easier for health care companies to bad-mouth and blame overpriced drugs than to acknowledge that they simply don’t want to cover you. This is not to say that drug companies don’t engage in price gouging—but the middle man passing on costs and taking cash out of your wallet is insurance, not Martin Shkreli.
These complex issues are just the tip of the iceberg America is crashing into while Donald Trump tweets that he’s king of the world. The GOP can’t repeal a policy it can’t replace, and it can’t manage an industry that pays its bills. The little wooden pieces of policy, which represent the lives and well-being of millions of Americans, will end up all over the floor. Except this time, the Republicans in Congress won’t have Obama or a Democratic majority to blame for it.
Jason Johnson, political editor at The Root, is a professor of political science at Morgan State’s School of Global Journalism and Communication and is a frequent guest on MSNBC, CNN, Al-Jazeera International, Fox Business News and SiriusXM Satellite Radio. Follow him on Twitter.