The new Congress convenes on Tuesday, and almost immediately Republicans are going to get the ball rolling on repealing the Affordable Care Act – eager to make headway even before Donald Trump takes office.
After more than 60 failed attempts to curtail or repeal the 2010 law, Republican lawmakers have their opportunity to make good on one of their top campaign promises. They seek to lessen government interference with people’s health coverage choices and relieve them of the punishing effects of mandates to buy insurance.
Democrats point to more than 20 million people who have gained coverage through Obamacare and argue that mandates to buy and offer insurance are necessary to support a market that includes high-risk individuals.
But the law’s individual insurance markets in many parts of the country are radically shrinking, even while premiums steeply rise. That has left many people with fewer, more costly choices.
“Given the dire situation facing our country, the time to act is now to deliver immediate relief for the American people,” said House Speaker Paul Ryan (R) of Wisconsin just before Christmas.
From Republicans’ first attempt to beat back the law until now, however, the overriding question has been: What would a GOP replacement look like? They haven’t been able to agree on one.
Not only is it still unclear what Republicans might rally around, a big question is over timing – whether Republicans are making a mistake by going quickly for repeal without first outlining what a replacement would look like.
“In some ways, I feel we’re putting the cart before the horse,” says Sen. Susan Collins, the Republican moderate from Maine. She wants a detailed replacement framework to accompany the repeal push. That could prevent uncertainty over a final outcome from disrupting insurance markets and service. Maine has 84,000 residents who are covered by the law.
Will GOP agree on a replacement in time?
The repeal legislation is expected to name some future date at which many key parts of Obamacare will end, allowing an interim period for participants to stay covered while a replacement is drafted.
Republicans disagree on when that date should be – perhaps three years hence, to allow plenty of time to draft a replacement, or sooner, before this Congress ends in two years and the GOP potentially loses its grip in midterm elections.
And while House Republicans have drafted a blueprint for replacement under their “A Better Way” agenda, Senate Republicans have yet to coalesce around any replacement plan.
So it’s not at all clear that Republicans in both chambers will be able to agree on a replacement in the given time frame, let alone get buy-in from Democrats.
Republicans can repeal with only a majority vote through a special budget process, but legislation to replace the law would have to clear a 60-vote threshold in the Senate, where Republicans hold a narrow 52-to-48 advantage.
That’s why Senator Collins thinks lawmakers need to see a detailed path forward upfront.
“I don’t want people falling through the cracks and losing their insurance status because we didn’t have a replacement ready to go,” she said in an interview, noting from her experience overseeing insurance for Maine that insurance markets “are complex and that they cannot turn on a dime.”
Her concern is backed up by a recent report by the center-left Brookings Institution think tank in Washington.
A repeal effort “would likely destabilize the individual market and very possibly cause it to collapse in some regions of the country during the interim period before any replacement is designed,” the Brookings report found.
“If you’ve said ‘this whole structure is gone,’ even if you set a date a year later or six months later, insurance companies are promptly going to begin making decisions, they’re going to change what they offer, where and at what prices,” said Sen. Chris Coons (D) of Delaware just before the holiday break. “I think it’s going to lead to chaos.”
A stabilization fund could help
Of course it would be preferable to have worked out a game plan, and particularly a bipartisan one, before a repeal vote, says G. William Hoagland, senior vice president at the Bipartisan Policy Center in Washington.
But he says there’s a great concern among Republicans of time wasted and perhaps an opportunity lost to repeal Obamacare at all if they wait to get everyone – including some Democrats – on board with a replacement plan.
One way to seize the day without triggering serious instability in the insurance market would be to provide in the repeal legislation a fund to help insurers weather the interim period, Mr. Hoagland says.
“I think what the insurers will want to know is not so much the end product, or replacement, but what will you do for the transition period to lessen volatility,” he says.
That appears to align with a comment provided to the Monitor by David Merritt, executive vice president of America’s Health Insurance Plans, the heath insurance trade association.
"While political realities will likely lead to a repeal vote before an effective replacement plan is outlined, consumers will be best served by an effective transition that delivers continuous coverage,” Mr. Merritt wrote in an email.
How the vote will work
The House committee that’s working on the repeal legislation promises more details soon. Broadly, Americans can expect to see a two-step process known as “budget reconciliation” that will allow Republicans to repeal key parts of Obamacare with just a simple majority vote in both houses.
The Senate is expected to take the first step in a vote – likely this week – that sets up the process. House Republicans are expected to follow suit on Jan. 9. This stage is expected to go easily.
It’s the second step, where the actual repeal vote takes place, where things could get dicey. The GOP might lack the votes they need in the Senate, Hoagland says.
Collins might balk at undoing coverage for 20 million Americans, even if the effect is delayed, with no replacement in sight. A couple senators on the right might think the repeal legislation doesn't go far enough, Hoagland adds. It would take only three Republican defections to kill the repeal vote if all Democrats stuck together in opposition.
In the meantime, Democrats want to turn up the heat on Republicans so that voting for repeal becomes too politically uncomfortable for some. President Obama will head to the Hill on Wednesday and meet with Democrats to discuss how to defend his healthcare legacy. It’s not clear whether they’ll succeed.