On health care, Donald Trump has spoken. His administration will present a plan to “simultaneously” repeal and replace the Affordable Care Act, he said on Wednesday. The plan will be presented shortly after the new health secretary is confirmed, probably in February.
The word from the GOP’s standard-bearer ostensibly settles a disagreement among Republican lawmakers. Some have argued for immediate repeal, with the replacement details to be worked out over a transition period. Others have demanded that a replacement be offered concurrently, so as not to spook insurance markets – or consumers – with uncertainty.
For years, Republicans have been united in their goal to repeal Obamacare, attempting to kill or alter the law more than 60 times. But they haven’t been able to unite around a replacement that gives people more freedom to make their own health choices while covering the 20 million Americans who currently get health insurance under the Affordable Care Act. That's in addition to fixing the skyrocketing premiums and shrinking choices in the law’s insurance marketplaces.
Might the outsider president-elect be able to lead them out of this thicket? Or will he himself become entangled in the complexities of health-care reform?
Lawmakers such as Rep. Chris Collins (R) of New York say Trump is just what’s needed to pull Republicans through the debates over multiple replacement plans that they’ve been discussing since the act became law in 2010.
“We’re going to take our lead off of President Trump,” said Congressman Collins, who is a member of the Trump transition team and a liaison between Trump and the Hill.
The troops will fall in line behind their general because they owe him a “debt of gratitude,” he told reporters Wednesday. Thanks to Trump’s victory, Republicans in Congress will be able to “get things we only dreamed about.”
Look at Trump’s impact two weeks ago, said Collins, when a mere tweet caused Republicans to back off their plans to greatly weaken the Office of Congressional Ethics.
“He tweets, and he effected that change instantly. That should give you an indication of how we will bend over backwards,” he said.
Collins pointed out that Trump’s timeline is “tighter” than the GOP leadership was talking about just a month ago. Indeed, this week House Speaker Paul Ryan announced that Republicans would “bring replace concurrent with repeal” – a change from previous statements about using an interim period to work out a replacement for the law.
He promised a “full, exhausting conversation” at the GOP retreat at the end of January to go through all of their plans, and said Republicans are “completely in sync” with the incoming administration about having a replacement ready at the same time as repeal. They are coordinating on a daily basis, he said.
And yet, things look different in the Senate, despite senators kicking off the repeal process with a party-line 51-to-48 vote early Thursday morning. The House is expected to follow on Friday. The Senate move engages a budget mechanism that requires only a majority vote in both chambers, culminating in the actual repeal vote, which comes later.
The Trump move toward simultaneous repeal and replace would seem to satisfy several Republican senators who have argued that rolling back the law without knowing what’s coming could upset insurance markets and hurt people covered by Obamacare.
But the president-elect’s urgency could hit a wall in the slow-moving Senate, where Democratic buy-in will be needed for repair work.
“To me, ‘simultaneously’ and ‘concurrently,’ means Obamacare should be finally repealed only when there are concrete, practical reforms in place that give Americans access to truly affordable health care,” said Sen. Lamar Alexander (R) of Tennessee, a key player in process, according to Roll Call.
He is calling for a “step-by-step” approach, as are others – including Congressman Ryan, even as he says time is of the essence in this “rescue mission.”
Republicans on the Hill and outside experts on health care are pointing to a multipronged approach to a replacement plan.
Some of it can be done through the special budget mechanism that requires only a majority vote. Some of it can be done through executive order and the considerable leeway that the secretary of Health and Human Services has to carry out the law – including a provision where he could grant states a waiver to design their own health-care insurance programs.
The rest would have to come through bipartisan legislative action – including a related health-care program for children, which faces reauthorization this year.
Not a quick fix
Some of these repairs can indeed be done quickly, says G. William Hoagland, a health-care and budget expert at the Bipartisan Policy Center in Washington. But Obamacare is complex, and fixing it is complex, he warns.
“The fundamental rebuilding of Obamacare into Trumpcare – I don’t think that’s anything that at all can be done in a quick manner,” he says. “This is very complicated stuff, with lots of interactions.”
At the same time, members of Congress have their districts and constituents to keep in mind. “With all due respect, the president-elect is not the CEO of the country,” he says.
And yet some Republicans remain hopeful that Trump can light a unifying fire under the fractious GOP.
“The time to move is now,” said Rep. Tom Cole (R) of Oklahoma, who is close to the House GOP leadership. “I think we’re going to be held accountable if we don’t produce legislation. The only thing Trump is telling [us] is what’s obvious.”