The ink from President Obama's signature on the Affordable Care Act wasn't even dry when then Senate Minority Leader Mitch McConnell unveiled the Republican mantra for the upcoming midterm elections. As he put it on March 23, 2010, "I think the slogan will be "repeal and replace", "repeal and replace."
Now, almost seven years later, McConnell and his Republican allies are finding out just how difficult their simplistic Obamacare proposition will really be. With Donald Trump weeks away from defiling the Oval Office, Congressional Republicans are no closer to a replacement plan for the roughly 25 million people they will soon add to the ranks of the uninsured. "Repeal and replace" has become "repeal and delay."
Meanwhile, worried House and Senate Republicans are getting an earful from almost every corner of the American health care industry. Having an already asked a federal judge to postpone action on the House GOP lawsuit challenging cost-sharing payments for 7 million Americans, Republicans have received dire warnings from health insurers about the death spiral their individual market will experience if no Obamacare replacement is immediately forthcoming. Hospitals have also alerted President-elect Trump and Congress that many of them will face financial ruin as millions of newly uninsured Americans once again require uncompensated care. While American Medical Association (AMA) President Andrew Gorman declared "a core principle is that any new reform proposal should not cause individuals currently covered to become uninsured," new assessments this week from ACASignups.net and the Urban Institute forecast that will be the fate for up to 29 million people who obtained coverage thanks to Obamacare. It's no wonder even Republican voters are losing their appetite for repeal.
Oh, and one other thing. Recent research suggests that the Republican repeal of President Obama's landmark health care law will result in tens of thousands of Americans needlessly dying every year.

This discussion of the American health care system's body count isn't a new one. In a 2002 study, the Institute of Medicine estimated that 18,000 Americans died in 2000 because they lacked health insurance. In January 2008, a study by the Urban Institute ("Uninsured and Dying Because of It") didn't just conclude that "the absence of health insurance creates a range of consequences, including lower quality of life, increased morbidity and mortality, and higher financial burdens." The national death toll, it found, was rising: "137,000 people died from 2000 through 2006 because they lacked health insurance, including 22,000 people in 2006." By 2012, Families USA ("Dying for Coverage: The Deadly Consequences of Being Uninsured") concluded that "uninsured adults are at least 25 percent more likely to die prematurely than adults who have private insurance" and found that "26,100 people between the ages of 25 and 64 who died prematurely due to a lack of health insurance in 2010." A 2009 analysis by Harvard Medical School and Cambridge Medical Alliance was gloomier still, warning "uninsured, working-age Americans have 40 percent higher death risk than privately insured counterparts." All told, the Harvard study lamented, each year "nearly 45,000 annual deaths are associated with lack of health insurance." That kind of horrifying data, along with a dramatic shift of health costs to individuals and families as employers curtailed or dropped coverage, helped propel the passage of the Patient Protection and Affordable Care Act in 2010. (Nevertheless, that didn't stop Republicans from George W. Bush, Tom Delay and Mitch McConnell to Mitt Romney and Phil Bryant to complain before and after Obamacare became law that "no one goes without health care" because "you just go to an emergency room.")
But with the Supreme Court ruling in the 2012 case of NFIB v. Sebelius, the issue of death by lack of insurance resurfaced. States, the Roberts Court declared, could refuse to expand Medicaid coverage as Obamacare originally required. Without the mandate to extend the joint federal/state insurance program to those earning up to 138 percent of the federal poverty level (FPL), 19 states decided to opt out. The predictable result, beginning in 2014, was a "coverage gap" which left millions of people uninsured. As the New York Times reminded readers again this week, those stuck in the gap in the non-expanding states earned too much to qualify for free Medicaid and too little to qualify for subsidies to purchase private insurance on the Obamacare exchanges. As Janet Foy, a Missouri resident caught in the GOP coverage gap put it this week:

"I'll take my chances with dying, if that's what it comes down to. We have no money."

In 2014, another team of researchers from Harvard Medical School warned in Health Affairs that lot of Americans--almost 7.8 million--would find themselves in Ms. Foy's situation. The authors of "Opting Out Of Medicaid Expansion: The Health And Financial Impacts" tallied up the coming body count in the Republican states that rejected the ACA's extension of Medicaid to millions of their residents:

Nationwide, 47,950,687 people were uninsured in 2012; the number of uninsured is expected to decrease by about 16 million after implementation of the ACA, leaving 32,202,633 uninsured. Nearly 8 million of these remaining uninsured would have gotten coverage had their state opted in. States opting in to Medicaid expansion will experience a decrease of 48.9 percent in their uninsured population versus an 18.1 percent decrease in opt-out states...
We estimate the number of deaths attributable to the lack of Medicaid expansion in opt-out states at between 7,115 and 17,104. Medicaid expansion in opt-out states would have resulted in 712,037 fewer persons screening positive for depression and 240,700 fewer individuals suffering catastrophic medical expenditures. Medicaid expansion in these states would have resulted in 422,553 more diabetics receiving medication for their illness, 195,492 more mammograms among women age 50-64 years and 443,677 more pap smears among women age 21-64. Expansion would have resulted in an additional 658,888 women in need of mammograms gaining insurance, as well as 3.1 million women who should receive regular pap smears.

The Republicans' killer math netted out this way. Of the 7,781,829 left uninsured, the authors estimated between 7,115 (0.091 percent) and 17,104 (0.220 percent)) would die for no reason other than political spite.
But Sam Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhandler weren't the only researchers trying to understand the carnage from policymakers' failure to enable health insurance coverage. As Ian Milhiser wrote in February 2015, another study counted up the bodies by reverse engineering the 2006 health care reform law in Massachusetts. During the 2015 King v. Burwell case that tried (and failed) to end insurance subsidies for those obtaining coverage in states with federal Obamacare exchanges, ACA supporters pointed to a 2014 study titled, "Changes in Mortality after Massachusetts Health Care Reform: A Quasi-experimental Study":

A brief filed on behalf of multiple public health scholars and the American Public Health Association, estimates that "over 9,800 additional Americans" will die if the justices side with the King plaintiffs. It reaches this conclusion by starting with an Urban Institute study showing that 8.2 million people will become uninsured in this scenario. As other research examining Obamacare-like reforms in the state of Massachusetts found that "for every 830 adults gaining insurance coverage there was one fewer death per year," that translates to between 9,800 and 9,900 deaths if the justices back the plaintiffs in King.

That 0.120 percent ratio--one unnecessary death for each 830 adults losing insurance--represents a middle ground in forecasting the lives wasted by killing Obamacare. While actuarial tables will doubtless vary based on the ages of those losing insurance and their source of insurance (generally poorer and undertreated on Medicaid), we can nevertheless get some ballpark figures for the death toll among those to be denied coverage by the new Republican monolith in Washington.
According to Daily Kos' own Brainwrap, the newly uninsured in President Trump's America will be a gigantic group. All told, the real Charles Gaba estimates with his state-by-state breakdowns, 23.1 million--or 7.2 percent of the entire population--will lose insurance as a result of the complete. immediate repeal of Obamacare in the spring of 2017. That figure includes 12.3 million who gained coverage through the expansion of Medicaid and around 9 million receiving subsidies to purchase private insurance on the ACA marketplaces. Another 1.4 million young adults under age 26 would be left without coverage, as would 470,000 still purchasing "basic health plans" grandfathered under Obamacare.
As the table at the top shows, the Grim Reaper Republicans would sentence thousands of Americans to death every year. Applying the low (0.091 percent), medium (0.120 percent) and high (0.220 percent) mortality rates from the 2012 and 2014 studies, the needless deaths among Gaba's 23.1 million newly uninsured would range between 21,148 and 50,852.
As shocking as those numbers are, the body count is even higher if Republicans choose to repeal Obamacare, but delay its implementation. That's the conclusion of a new analysis released this week by the Urban Institute. In "Implications of Partial Repeal of the ACA through Reconciliation," Linda J. Blumberg, Matthew Buettgens and John Holahan compared "future health care coverage and government health care spending under the ACA and under passage of a reconciliation bill similar to one vetoed in January 2016." Their top line findings:

The number of uninsured people would rise from 28.9 million to 58.7 million in 2019, an increase of 29.8 million people (103 percent). The share of nonelderly people without insurance would increase from 11 percent to 21 percent, a higher rate of uninsurance than before the ACA because of the disruption to the nongroup insurance market.
Of the 29.8 million newly uninsured, 22.5 million people become uninsured as a result of eliminating the premium tax credits, the Medicaid expansion, and the individual mandate. The additional 7.3 million people become uninsured because of the near collapse of the nongroup insurance market.

"This scenario does not just move the country back to the situation before the ACA," they concluded, "It moves the country to a situation with higher uninsurance rates than was the case before the ACA's reforms."

That grotesque outcome would be perverse result of the path Republicans in Congress are now plotting to pursue in their "repeal and delay" approach to Obamacare. As Ian Milhiser explains, gutting the regulatory aspects of the 2010 Affordable Care, such as the requirement that insurers cover people with preexisting health conditions, are subject to filibuster and thus effectively require 60 votes in the Senate.

Meanwhile, legislation repealing the law's fiscal provisions -- including the Medicaid expansion, tax credits that help people pay their health premiums, and the law's individual mandate (which charges higher income taxes to people without insurance) -- can be enacted by a simple majority through a process known as 'reconciliation." For this reason, Senate Republicans are considering repeal of just the fiscal provisions in order to overcome a Democratic filibuster.
Repealing only these provisions, however, would actually be worse for Americans in the individual health insurance market than a total repeal of the law. That's because the law's provisions protecting people with preexisting health conditions cannot operate without the tax credits and the individual mandate.
The mandate, in particular, is essential because it encourages people to purchase health insurance before they become sick. Without it, many healthy individuals will wait until they are sick to buy insurance, effectively draining all the money out of an insurance pool they haven't paid into. Eventually, many insurance pools would simply collapse.

That is why the Urban Institute warns that President Trump, Senate Minority Leader McConnell and House Speaker Paul Ryan are poised to make American health care worse than it was prior to President Obama's signing of the Affordable Care Act in March 2010. It's why the health insurance industry, the hospital industry and the AMA are all raising red flags. And the GOP's scorched-earth campaign destined to lay waste to American health care has led Brian Beutler to counsel Republicans that "the alternative to Obamacare is Obamacare." Kevin Drum's warning went a step further: "Obamacare repeal is doomed."
Alas, Kevin Drum is probably underestimating the depth of the almost bottomless well of Republican political spite. Despite the fact that Uncle Sam was picking up nearly the entire tab for Medicaid expansion, 19 GOP-controlled states still said no. They didn't just condemn thousands of their residents to early graves, but jeopardized state budgets and hospitals while doing it. Florida Senator Marco Rubio led Congressional Republicans in stripping billions of dollars in guaranteed risk adjustment funding for Obamacare insurers, despite the fact that Medicare (including Medicare Advantage for private insurers) has been using them for year. Almost nine-hundred thousand people lost their existing coverage as a result, as non-profit co-ops were wiped out and many insurers bailed on markets across the country (especially in rural areas). And even as they promise to repeal Obamacare "root and branch," the Republicans don't really mean it. The $879 billion in savings the Affordable Care Act extracted from Medicare insurers and providers between 2016 and 2025 isn't going away: Paul Ryan, Tom Price (R-GA) and friends as always are planning to redirect to massive tax cuts for the wealthy.

During the 2012 presidential campaign, RNC chairman and incoming Trump chief-of-staff Reince Priebus regurgitated a tried and untrue GOP talking point. President Obama, Priebus falsely charged, "stole $700 billion from Medicare to fund ObamaCare" before adding:

"If any person in this entire debate has blood on their hands in regard to Medicare, it's Barack Obama."

After all the Republicans' killer lies about "death panels" and a "government takeover of health care" and "pulling the plug on grandma," Priebus' "blood on their hands" slander is perhaps the most vicious of all. Barack Obama and his Democratic Party made it possible for some 25 million Americans to obtain health insurance. Now as Donald Trump prepares to take the oath of office, GOP leaders are scheming to take it away from all of those people--and likely even more. Even if the grim math is overhyped, discussing a body count 60,000 or 40,000 or 20,000 dead Americans is an obscenity. Voting Republican, as Mitch McConnell once said of a public health insurance option for Obamacare, "may cost you your life." If Trump, McConnell and Ryan repeal Obamacare, let there be no doubt who had blood on their hands.