Last January, congressional Republicans finally succeeded in getting a bill to President Obama’s desk that would repeal the Affordable Care Act and pave the way for major GOP replacement ideas. Obama, of course, vetoed the bill and allowed his long-embattled signature health insurance plan to continue.
Today, Senate Majority Leader Mitch McConnell told Politico that the GOP intends to keep its promise – which could happen as early as January – when a newly ensconced President Donald J. Trump will be sitting in the Oval Office. McConnell said, "It's pretty high on our agenda as you know," the Kentucky Republican said on Wednesday. "I would be shocked if we didn't move forward and keep our commitment to the American people."
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The 2010 Affordable Care Act – which has provided more than 20 million Americans with subsidized and market rate health care insurance – survived two legal challenges that made it all the way to the Supreme Court and more than 50 attempts by hostile Senate and House members to kill the program through legislative action.
But Obamacare appears to be the biggest casualty of Tuesday night’s stunning election results. Trump, the billionaire businessman who spent the waning days of the campaign denouncing Obamacare and promising to repeal it, soundly defeated Democrat Hillary Clinton, who devoted much of her campaign to defending the program and vowing to build on it.
Now, with a Republican in the White House beginning January 20 and the GOP retaining firm control of the Senate and House, lawmakers and health care policy experts agree that the axe will fall on the program early next year – possibly even before Trump is sworn in as president. Trump has repeatedly denounced Obamacare for its soaring premiums and financial instability and has promised that repealing the program would be among his first acts in office.
House and Senate GOP leaders are mulling the idea of having the legislation repealing Obamacare waiting for Trump on Inauguration Day.
“I think they’re serious,” John McDonough, a Harvard University public health professor who worked with Senate Democrats to draft and pass the Affordable Care Act, said in an interview on Wednesday. “How many times do they have to say it before we say, ‘Okay, we get it, you really mean it.’”
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“This is not a drill,” he added. “This is the real deal.”
Larry Levitt, senior vice president at the Kaiser Family Foundation, said in an interview with The Washington Post today that Obamacare may be on its last leg. “The ACA as we know it would seem to be toast,” he said.
The landmark program championed by President Obama mandates uninsured Americans to obtain coverage provides an array of individual policies and tax subsidies for lower income Americans. It greatly expands health insurance coverage for the poor under Medicaid and allows parents to keep their children on their family policies through age 26. And it offers consumer protections including a ban on insurers denying policies to applicants with pre-existing health problems.
Summarily dismantling that program without an adequate replacement would pose a stunning setback for millions of Americans who would eventually lose their current level of coverage and have to settle for something far less comprehensive – or nothing at all.
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The Republicans have been long criticized for waging war on Obamacare without offering a viable alternative. Indeed, House Republicans for years routinely brought up and passed measures to financially cripple or kill off Obamacare, but they invariably stalled in the Senate, where Republican leaders couldn’t muster the minimum of 60 votes needed to pass major legislation.
That began to change last winter after House Budget Committee Chair Tom Price (R-GA) introduced a bill tailor-made for the reconciliation process in the Senate. Price’s bill would repeal Obamacare’s mandates on individuals and businesses and eliminate tax credits for lower income people by the end of 2017, as VOX explained today. That bill would also end the ACA’s Medicaid expansion while creating a two-year transition period to give the GOP more time to come up with a suitable replacement.
Republicans are in general agreement that one of the most popular provisions of Obamacare -- allowing children to remain on their parent’s health insurance plans until they turn 26, will be preserved, as well as some variation on the ban discriminating against applicants with pre-existing health care problems. And Trump has indicated that he would support preserving the existing expanded Medicaid coverage in 31 states and the District of Columbia, but not allowing other states to do the same.
Christopher Condeluci, a health care expert who worked for Republicans on the Senate Finance Committee during the debate over Obamacare, said that GOP leaders were well aware of the risks of trying to immediately cut off benefits to millions of Americans and came up with the idea of a two-year transition. The Congressional Budget Office estimates that unless a new plan is offered, 22 million people would lose insurance under Price’s plan after the two-year transition policy ended.
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“That transition period serves two purposes,” Condeluci said in an interview today. “One, it insulates the Republican policy makers from getting beat up over, ‘Hey, you’re kicking 20 million people off of insurance,’ because that’s not going to happen immediately.”
“The second purpose is, they needed a transition period so that they could figure out what to replace it with,” Condeluci added. He said that before House Speaker Paul Ryan (R-WI) unveiled his comprehensive “Better Way” proposal for health care reform last summer, “there was really no credible replacement proposal that House Republicans coalesced around.”
Ryan’s 37-page plan was not written in the form of legislation but instead is a general discussion of plans to reform Medicare and Medicaid – including providing Medicaid block grants to the states and Medicare premium supports for younger Americans. It also proposes incentives for employers to expand health care coverage to their employees.
Senate Republicans haven’t weighed in on Ryan’s proposal yet, and are likely to advocate a different approach. But House Republicans are largely in agreement with Ryan’s approach, according to Condeluci.
Trump has repeatedly called Obamacare a “disaster” and offered a series of mostly half-baked alternatives, including encouraging health insurance sales across state lines to increase competition among insurers and bring down premium costs. He has also endorsed the wider use of medical savings accounts to help defray the cost of coverage.
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Robert Laszewski, a consultant on health care issues, said today that there is absolutely no doubt that Trump and the Republicans will go ahead with their threat to dismantle Obamacare as early as possible, but warned that the new administration and GOP leadership will be entering treacherous terrain.
“A fully ideological Republican plan that doesn't pay attention to how this market really works could put the Republicans right back where the Democrats are today,” he wrote in a blog post, noting that Obama and congressional Democrats passed the legislation without the support or input of a single Republican.
“The best news here is that defunding and then replacement of Obamacare could ironically set the table for the first real bipartisan legislative effort in a very long time,” he added. “The one we should have had in the first place.”
