The New England Journal of Medicine has this piece by a liberal at the Brookings Institute worrying about how to protect Obamacare.
My concern is that Obamacare is a disaster, but that Obama and Democrats will claim that it just didn't work because of this lack of funding. The program itself will then escape the disapproval that it deserves.
Repeal of the ACA before 2013 is unlikely. Both houses of Congress would have to enact repeal legislation, which President Barack Obama would surely veto. Then, two thirds of both houses would have to vote to override that veto. After 2012, however, repeal could occur if Republicans win the White House and both houses of Congress and stick by their pledge.
A more serious possibility is that ACA opponents could deliver on another pledge: to cut off fund ing for implementation. Here is how such a process could work.
Customarily, substantive legis lation “authorizes” spending, but the funds to be spent must be separately “appropriated.” The ACA contains 64 specific authoriza tions to spend up to $105.6 billion and 51 general authorizations to spend “such sums as are neces sary” over the period between 2010 and 2019. None of these funds will flow, however, unless Congress enacts specific appro priation bills. In addition, section 1005 of the ACA appropriated $1 billion to support the cost of implementation in the Depart ment of Health and Human Services (DHHS). This sum is a small fraction of the $5 billion to $10 billion that the Congressional Budget Office estimates the fed eral government will require between 2010 and 2019 to im plement the ACA. The ACA ap propriated nothing for the Inter nal Revenue Service, which must collect the information needed to compute subsidies and pay them. The ACA also provides unlimited funding for grants to states to support the creation of health in surance exchanges (section 1311). But states will also incur sub stantially increased administrative costs to enroll millions of newly eligible Medicaid beneficiaries. Without large additional appropriations, implementation will be crippled.
If ACA opponents gain a ma jority in either house of Congress, they could not only withhold needed appropriations but also bar the use of whatever funds are appropriated for ACA imple mentation, including the imple mentation of the provisions re quiring individual people to buy insurance or businesses to offer it. They could bar the use of staff time for designing rules for implementation or for paying sub sidies to support the purchase of insurance. They could even bar the DHHS from writing or issu ing regulations or engaging in any other federal activity related to the creation of health insur ance exchanges, even though the ACA provides funds for the DHHS to make grants to the states to set up those exchanges.
That would set the stage for a highstakes game of political “chicken.” The president could veto an appropriation bill containing such language. Congress could refuse to pass appropria tion bills without such language. . . .
My concern is that Obamacare is a disaster, but that Obama and Democrats will claim that it just didn't work because of this lack of funding. The program itself will then escape the disapproval that it deserves.
the effort to repeal the bill will not succeed, but the tactic of crippling imple mentation will. The nation would then be left with zombie legisla tion, a program that lives on but works badly . . .
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How to stop Obamacare
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