While the impact to state Medicaid programs under this proposal would be less substantial than the BCRA’s radical funding changes and major cuts over two decades, the loss of the Medicaid expansion would also have major effects. Upward of 15 million people—depending on state decisions to continue or discontinue covering them—would lose coverage, and they would find themselves without exchange plans to turn to. This population includes many or most of the able-bodied adults enrolled under Medicaid today, and removing funding for their coverage could destabilize public-health efforts against the opioid crisis and other drivers of mortality among non-elderly adults.
A repeal-and-delay plan wouldn’t just affect coverage and premiums. Rather, the withdrawal of billions of dollars poured into state governments and into subsidized coverage would amount to a sudden removal of a stimulus. Recent analyses have shown that a repeal-and-replace plan like the BCRA’s House predecessor, the American Health Care Act, would decrease total jobs by about a million, cut total state gross-domestic products by $93 billion, and curb total business output by $148 billion by 2026—losses that would be concentrated in the health industry, but felt across every sector.
But those losses are downright rosy compared with earlier projections for the 2015 repeal-and-delay plan that Obama vetoed. One January study from Commonwealth Fund and George Washington University researchers found that such a plan would erase around 3 million jobs, $1.5 trillion in gross state products, and $2.6 trillion in total business activity in the four years after its completion.
Now, all of these effects assume only the “repeal” portion of repeal-and-delay. Hypothetically, a replacement—even if it turned out to just be a revived BCRA—would offset many of the most disruptive effects, provide money for the exchanges to start running smoothly again, and provide some funding mechanisms for the poorest and sickest patients. But in the words of McConnell at his press conference Tuesday: “It’s pretty obvious that we don’t have 50 members who can agree on replacement.”
The last five months have been a blur of rushed and secret bills, backroom deals, intra-party revolts, deteriorating public opinion, and a president who waffles weekly about his most basic stances on health policy. The repeal-and-delay option hinges on the Senate being able to do exactly what they just failed to do, and every quantum of risk that they fail again would inflate premiums and slough even more people off coverage. As Murkowski stated in her decision not to back McConnell’s Plan B, “there’s enough chaos and uncertainty already, and this would just contribute to it.”
Even with objections like Murkowski’s, as long as McConnell is Senate majority leader, it seems unlikely that the prospect of Obamacare repeal will really ever go away. The margins are too thin, and opportunity will inevitably come knocking again at some point down the road. And under the most cynical interpretation, the repeal-and-delay option is an effective backup plan because it would basically create a time bomb: As the months ticked away, moderate Republicans or even Democrats would have to get on board to create a replacement plan that averts the total collapse of exchange markets and the ejection of over 30 million people into the ranks of the uninsured.