Iowa's health insurance exchange this week became the poster child for self-fulfilling prophecies.
In just 72 hours, Iowa's version of the Affordable Care Act, or Obamacare, crumbled under its own weight and the additional heft a Republican White House with no interest in supporting it.
Wellmark Blue Cross and Blue Shield and Aetna last week both announced departures from Iowa's exchange in 2018, citing mounting financial losses and continued "uncertainty." That leaves Iowa's exchange with just one provider, Medica, which has yet to make its future intentions known. Wellmark and Aetna represent a majority of the Iowa exchange's total plans.
So, now what?
What's clear so far is Republicans in Washington have no answers.
Obamacare has always been a highly compromised, deeply troubled program. Even proponents of the massive federal program lamented its shortcomings. It's over-reliance on young, healthy populations to subsidize the elderly and sick didn't pan out. Obamacare was costly and clunky. But, by most objective measures, it was relatively successful.
Roughly 20 million Americans have health insurance thanks to the ACA. In 2016, national insurance rates reached a record low of 10.6 percent, according to Gallup. That's down from 18 percent in 2013, and it's the working poor -- a population who spent decades one heart attack away from financial ruin -- who benefited most.
An imperfect program, for sure. But Obamacare isn't responsible for the country's astronomically high health care costs. Americans pay more and get less relative to the rest of the developed world, according to the World Health Organization. It even slowed the incessant rise of health insurance premiums, concluded the Congressional Budget Office.
Republicans spent seven years wasting time on meaningless votes to repeal ACA. It was a go-to foil in congressional districts in every purple district throughout the country. It was "evil," they said. They stoked nonsensical fears about "death panels." President Donald Trump has repeatedly called it a "disaster" without bothering to actually understand it and last month promised to let ACA fail when his party couldn't offer any real solutions.
That last bit is the "uncertainty" to which Aetna and Wellmark officials were referring. Trump's promise to starve ACA to death all but doomed an already troubled Iowa exchange.
The White House and congressional Republicans, still smarting after last month's failure, spent much of last week in closed-door meetings trying to hash out a replacement to ACA, reported the New York Times. Most of the talks involving the White House concerned placating the GOP's right-wing Freedom Caucus, which killed the party's first attempt at repeal. Proposed concessions included high-risk pools, a downright scam that's failed in multiple states, and the elimination of hugely popular pre-existing conditions protections for consumers.
A bill that already turned the noses of the GOP's reasonable center reeks even worse after this week. Flailing is fine for a minority party. Chaos is not acceptable for the majority that's supposed to govern.
So, we ask again: What now?
Republicans tapped widespread confusion and fear to score political points off Obamacare. They've railed against it without any real solution. They're now actively destabilizing it. And, predictably, Iowa's exchange is quite literally falling apart amid a GOP civil war.
The well-being of thousands of Iowans are at stake here. More than 50,000 benefit from taxpayer subsidized policies on Iowa exchange. Tens of thousands of Iowa's poorest rely on the state's already foundering Medicaid system, expanded as part of the ACA and privatized by Gov. Terry Branstad.
And the very people who sowed discontent and stoked fears have, so far, proven incapable of picking up the pieces.