The Specifics Of ACA Defunding

Proponents of the health reform are starting to worry that if the Republicans can’t practically repeal the Affordable Care Act, they can do a lot of damage to the law by defunding it. Henry Aaron has a good piece in New England Journal of Medicine about what exactly the GOP can do:

Repeal of the ACA before 2013 is unlikely…A more serious possibility is that ACA opponents could deliver on another pledge: to cut off funding for implementation.3 Here is how such a process could work.

Customarily, substantive legislation “authorizes” spending, but the funds to be spent must be separately “appropriated.” The ACA contains 64 specific authorizations to spend up to $105.6 billion and 51 general authorizations to spend “such sums as are necessary” over the period between 2010 and 2019. None of these funds will flow, however, unless Congress enacts specific appropriation bills. In addition, section 1005 of the ACA appropriated $1 billion to support the cost of implementation in the Department 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 federal government will require between 2010 and 2019 to implement the ACA. The ACA appropriated nothing for the Internal 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 insurance exchanges (section 1311). But states will also incur substantially increased administrative costs to enroll millions of newly eligible Medicaid beneficiaries. Without large additional appropriations, implementation will be crippled. [...]

[Republicans] could bar the use of staff time for designing rules for implementation or for paying subsidies to support the purchase of insurance. They could even bar the DHHS from writing or issuing regulations or engaging in any other federal activity related to the creation of health insurance exchanges, even though the ACA provides funds for the DHHS to make grants to the states to set up those exchanges.

In my interview with him on Tuesday, Tom Daschle suggested that defunding the law may be more difficult than it seems, since “a lot of what we did in health care reform has more of an entitlement than a discretionary funding base. So as an entitlement, they would really have to change the law rather than simply not fund in order for it to be effected. The entitlement sections of the legislation are going to be fairly immune from defunding,” he predicted. Indeed, the CBO estimates that there is “at least $50 billion in specified and estimated authorizations of discretionary spending that might be involved in implementing that legislation” and presumably that’s the spending they can most easily target.

Aaron is probably right about the GOP’s strategy, although I’m struck by the fact that if they successfully defund the law, they could then be blamed for the health care crisis that that creates (perpetuates). Could they not be made to own the status quo?