President Donald Trump and Republicans rail against Medicare-for-all. It would "really be Medicare for none," Trump claims. It's "socialist," Republicans routinely claim, with "exorbitant" costs. Sen. Rick Scott, R-Fla., said it would "just ruin our health care system, " adding "It's going to ruin Medicare."

All this begs the question of what Republicans think would happen if the courts deem the Affordable Care Act unconstitutional, an outcome that appears increasingly likely. On Tuesday in New Orleans, the U.S. Court of Appeals for the 5th Circuit heard arguments in a case that is seeking to do away with the ACA. Legal analysts listened to the session, increasingly aghast, as they came to believe it seemed more than possible that two of the three judges hearing the case would rule against supporters of the law. This will likely result in the Supreme Court once again weighing in on the issue, with the outcome by no means guaranteed.

It's often said that the American health-care system is a Rubik's Cube, a complicated but functional system to satisfy a basic need. One of the thoughts that supporters of the Affordable Care Act comforted themselves with as the Republicans took aim at the ACA time and time again, was that the threat of repeal could not be serious, that the law was too embedded in the health-care system to actually be overturned.

But if the 5th Circuit upends the ACA, and if the Supreme Court upholds that decision, it is possible that, instead of a Rubik's Cube, it would be better to think of our health-care system as one of my favorite childhood games, Kerplunk. In Kerplunk, you place sticks through holes in a cylinder, making a rickety floor. You place marbles on top of them. Then players begin to pull out the sticks one by one. Eventually, marbles begin falling. The Affordable Care Act is a stick that holds up a lot more marbles than most of us realize. It's not simply a way for Americans lacking access to employer-based health insurance to get access to coverage. It is responsible for ensuring that all Americans can receive insurance, regardless of preexisting conditions. It's why there are no longer caps on how much a policy will pay out on behalf of a customer.

While out-of-pocket health-care costs continue to rise, courtesy of the increasing number of insurance plans with four-figure deductibles, it is likely that costs would be even higher minus the ACA which, incentivized efficiency in hospital admissions and re-admissions, as well as medical treatment. It had a positive financial effect on so-called safety-net hospitals in states that expanded Medicaid. Minus the ACA, it is likely the opioid crisis will worsen, in part because the law forces insurers to offer coverage to help people overcome addiction and, in part, because people addicted to drugs are disproportionately more likely to receive their health coverage through Medicaid.

As for voters who would like to see the government "get their hands off" their Medicare, without the ACA, they'll get a taste of what that's like. As Tricia Neuman, a senior vice president at the Kaiser Family Foundation, told The New York Times, the ACA "touches virtually every part of Medicare." According to a recent Kaiser report, a repeal would likely raise Medicare beneficiaries out-of-pocket costs considerably, as well as put significant financial pressure on the system's trust fund.

The result of all this? If the ACA is ultimately deemed unconstitutional by the Supreme Court, millions of Americans will lose their health care while, at the same time, everyone else will discover that their costs are rising significantly - even as their plans cover less and less in the way of services. And that's just what we know will happen. There's a good possibility that taking out the ACA will also impact the system in ways we can't predict, except to say that it would almost certainly be bad. "The Trump DOJ's position in court, right now, which they argued today, is every bit as 'radical' and 'disruptive' as people say Medicare-for-all would be," noted MSNBC's Chris Hayes Tuesday on Twitter.

So why isn't this, per Hayes' comment, getting discussed as the radical bit of nihilism that it essentially is? Well, Republicans benefit from the tyranny of low expectations. We don't expect them to act responsibly. We expect the Democrats to do so, and we hold them to a higher standard as a result. Those who lean to the left are repeatedly castigated for embracing Medicare-for-all minus a detailed and specific outline for how it will be paid for, while Republicans are rarely challenged on how repealing the ACA will weaken the entire American health-care system as we know it. At the same time, many believe the Republicans are fighting the ACA as a show for their rabid base, and aren't serious about taking it out. As a result, all too many can't bring themselves to accept that Republicans might be for real, that they want to destroy the ACA, and they don't much care about what happens individual Americans or the entire health-care system as a result.

It seems almost delusional to expect voters to simply take this on the chin if and when it actually occurs. My prediction? If we think there is significant support for a major Medicare expansion now, we ain't seen nothing yet. It would be one of the great ironies of all time if it were Donald Trump and the Republican Party who all but forced people to turn to the "socialist" Medicare system to save health care. But it's an irony that's increasingly not outside the realm of possibility.

Make sure you never miss our editorials, letters to the editor and columnists. We’ll deliver the Journal’s Opinion page straight to your inbox.

Load comments