The occupier of the Oval Office is still, inexplicably, trying to spin the straw of Barr report of the Mueller report into Trumpcare gold. "If the Supreme Court rules that Obamacare is out, we'll have a plan that is far better than Obamacare," he told reporters at the White House. Like we haven't heard that from him—and every other Republican since 2010—before. Also Trump, showing that he really wants to do this: "I understand health care now, especially, very well. A lot of people don't understand it."
Dear reader, he doesn't. There's no plan because they simply can't do it. There isn't another option out there for doing everything that the Affordable Care Act does while maintaining the private health insurance industry. There is no conservative silver bullet that will force insurers to make sure everyone who has a pre-existing condition can keep and afford coverage and do everything else that Obamacare does. Look at Trump's own "solution": the rule that allows the sale of what are supposed to be very short-term crap policies for periods as long as three years. These plans can deny coverage of pre-existing conditions, they can charge women and older people as much more as they want, they can set caps on how much they'll pay out in coverage. Trump's solution is reverting to the pre-ACA health system. That's evidenced by the fact that since he got into office another 7 million people lost their coverage and joined the ranks of the uninsured.
To demonstrate just how much a Republican plan would have to do to replace the ACA, consider how much—of the entire reworked healthcare system—could be demolished if Trump prevails in court. Start with the 20 million or so people who've gained coverage by 2017 through the individual ACA markets and the Medicaid expansion (minus the 7 million who lost it already under Trump). That's just the beginning.
The Kaiser Family Foundation summarizes just the top-line achievements that are at risk: "the expansion of Medicaid eligibility for low-income adults; required coverage of preventive services with no cost sharing in private insurance, Medicare, and for those enrolled in the Medicaid expansion; phase-out of the 'doughnut hole' gap in Medicare drug coverage; reductions in the growth of Medicare payments to health providers and insurers; new national initiatives to promote public health, the quality of care, and delivery system reforms; and a variety of tax increases to finance these changes." KFF also has at hand public opinion surveys on all this. For example, 77 percent of voters support Medicaid expansion. An even bigger percentage, 81 percent, supports the ACA's subsidies to low- and middle-income people to afford private insurance.
How about the coverage for people up to age 26 on their parents' plans? That has 82 percent approval, and yep, it would be gone except for in a handful of states that have mandated it. Likewise, 82 percent support the existence of the exchanges, the marketplace where people and small businesses can shop for insurance. When you get to the core protections of the ACA, including the protections for people with pre-existing conditions, you see where the politics of 2018 come into play, because "just" 65 percent of voters want those protections preserved (just 58 percent of Republicans support that one). How about preventive services with no additional co-pay? That gets back up to 79 percent approval. How about Medicaid expansion? That's at 77 percent. How about the Medicare "doughnut hole"? Closing that is popular with 81 percent of voters. The litany of things this law does that people love could go on and on, and does at KFF. That will play into the politics in 2020 with Trump pursuing this.
But there's also the consequences of it really happening, consequences you can bet the judges on the 5th Circuit and Supreme Court Chief John Roberts are considering hard right now. Like the $874 million now being spent on breaking the opioid epidemic through Medicaid expansion. Imagine the opioid epidemic being that much worse, that many more people dying. Imagine the healthcare jobs that have been created in so many states because of Medicaid expansion drying up. Imagine the 133 million people with pre-existing conditions and the 171 million who no longer have to worry about caps on expensive treatments losing that peace of mind. Or the 60 million Medicare enrollees who would face higher premiums, changes to their care, and more expensive prescription drugs.
The ACA touches just about every aspect of healthcare delivery in the country, and that system has rebuilt itself remarkably in the past decade to conform to the law. Disrupting that would be seriously damaging, socially and economically. Trump might be clever enough to understand that, but I wouldn't bet on it. He is unscrupulous enough not to give a damn about the consequences.