How Republicans plan to end Obamacare, and what they might replace it with

REUTERS/Jonathan Ernst
Congressional Republicans are expected to waste little time before rolling back key aspects of the Affordable Care Act. Their next moves will prove more difficult.

Republicans arrived in Washington for the new year dead-set on doing something they’ve been talking about for years: repealing the Affordable Care Act, and replacing it with something else.

On Tuesday, the very first day of the 115th Congress, Republicans wasted no time, introducing legislation in the Senate that begins the process of repealing Obamacare.

Now in control of both chambers of Congress, and soon the White House, Republicans should have an easy enough time with all this, right?

Wrong: The task of dismantling Barack Obama’s sweeping health care law will still be a daunting one.

GOP lawmakers must craft a nuanced repeal plan that adheres to legislative procedure and gives them time to cook up a suitable replacement, all while keeping the U.S. health care market stable, and preserving the coverage of the estimated 22 million people who obtained coverage through Obamacare.

Partial repeal

First things first: before they replace Obamacare, Republicans have to repeal it. But that won’t be easy.

Though it would easily pass the House of Representatives, a repeal bill would stall in the Senate, where the GOP holds 52 seats — eight short of the number needed to overcome a Democratic filibuster.

But there’s a way around that filibuster: budget reconciliation. This legislative tactic allows bills related to spending, taxes, and the budget to pass the Senate with a simple majority vote, with debate limited to 20 hours, and no filibusters.

We got a preview of what that looked like in 2015, when Republicans did a practice run of a reconciliation-driven repeal — the only one of their many ACA measures to make it to Obama’s desk for a veto.

That bill would get signed into law by President Donald Trump starting January 20. But because of the rules of reconciliation, any GOP repeal efforts would be more limited in scope.

The 2015 legislation is a guidepost to what Republicans can take out of Obamacare using reconciliation, and what they cannot.

They would immediately be able to take aim at some of the law’s most critical aspects. The 2015 bill included language that eliminated the individual penalty for not having health insurance, effectively killing the ACA’s so-called health insurance “mandate.” It also curbed the federal government’s authority to operate exchanges where consumers could buy plans, such as Healthcare.gov.

It is expected that any GOP repeal plan going forward would also eliminate subsidies that the ACA provides for lower-income people to purchase health insurance, along with the taxes the law places on insurance companies and on medical devices.

Some key elements of Obamacare, however, cannot be dislodged through the reconciliation process. For example, the ACA’s guarantee that those with pre-existing conditions cannot be denied insurance coverage could not get repealed, because it doesn’t pertain to the budget. Neither does the law’s language that individuals can stay on their parents’ health plan through age 26.

Third District Rep. Erik Paulsen, who serves on the House Ways and Means Committee that crafts health care law, advocated for getting rid of the most onerous aspects of the law as soon as possible.

“The death spiral that’s going on right now, if we don’t take action quickly, February, March, we will see double digit premium increases again,” Paulsen said. “The bottom line is it’s our intention making sure anyone who is covered remains covered, that we have a transition in place, but we’re taking immediate steps to repeal Obamacare.”

But those on the right and left see some serious problems with repealing some elements of the ACA while keeping others in place.

According to Jim Capretta, a fellow at the center-right American Enterprise Institute, getting rid of the individual mandate but keeping other things, like the protection for those with pre-existing conditions, could have hugely adverse effects on the market.

Without the mandate — the incentive to purchase care — healthy people won’t purchase plans, leading to “larger insurer losses and a real exodus of insurance plans from the marketplace in 2018,” Capretta said.

Kevin Drum of the left-leaning Mother Jones magazine points out a further problem: that the only people who purchase plans on the exchange will be those who are prompted to after getting a catastrophic diagnosis, like cancer. That would further drive up costs and destabilize the system.

But retaining pre-existing conditions protections is popular. Even if they could, there is little will among top GOP leaders to attack that provision.

Considering a replacement

Whatever the risks of their strategy, President-elect Donald Trump and the GOP Congress are under immense pressure to act on Obamacare now.

Republican lawmakers expect the repeal package, whatever form it takes, to clear Congress in a matter of months. Then they would have a transition window — perhaps as long as four years — to pass a replacement as portions of the ACA are gradually phased out.

This is where things could get even harder. Republicans have broad ideas of what health care reforms they want to make: overall, they envision a system that reduces the federal government’s role significantly and returns to the private sector, and the states, key care decisions that they believe will lower costs for individuals.

But currently, there is no definitive plan that leaders have advanced. At the moment, GOP lawmakers are touting Speaker Paul Ryan’s so-called “Better Way” plan, which outlines certain reforms to the health care system. But it’s more like a blueprint than anything resembling a bill.

Republicans have taken stabs at an Obamacare replacement before, most recently the Patient CARE Act, written by Sens. Richard Burr, R-North Carolina, and Orrin Hatch, R-Utah.  

Hailed by some as a serious Obamacare alternative, Patient CARE centered on providing tax credits to help some individuals pay for health care, which could be used in a more flexible manner — like being deposited in a health savings account, a tax-protected savings account that people on high-deductible plans can use to pay for medical expenses. The tax credits would be adjusted based on need, taking into account an individual’s age and poverty level.

That legislation could influence any upcoming replacement. Other popular ideas within the GOP include expanding the use of health savings accounts, allowing the sale of health insurance across state lines, and expanding the ability of small businesses to pool coverage to increase their bargaining leverage with insurers.

Sixth District Rep. Tom Emmer said he wants any replacement plan to include increased authority to states.

“Minnesota was a leader in this before we force-fed the one-size-fits-all, top-down solution from Washington,” he said. “I think we should empower our state legislators, our leaders, to put together the plan that best fits our state.”

It’s unclear whether what form the replacement would take — either in pieces passed incrementally or in one large bill.

Paulsen said it could take several forms, but emphasized it’s coming swiftly. “All of the provisions and ideas that have been talked about with the Better Way agenda, all of these components, whether we roll it out in stages or we kind of put it together in a health care package, it’s going to happen soon,” he said, adding that it could be this year.

But Paulsen invoked Obamacare in pushing back against a big-bill approach. “I do believe that it’d be a mistake to do a 2,600-page bill,” he said, “and push it through without an understanding of what the real ramifications are and what the implications are.”

It’s still early, but health care experts have suggested there’s little in current GOP plans to mitigate the adverse effects of the partial repeal of the ACA. Some things they could pursue to keep the market stable until replacement — like maintaining the individual mandate — could be too hard for some Republicans to swallow.

Democrats may provide key votes

Democrats, in the minority in both chambers and out of the White House, acknowledge there’s little they can do to stop the GOP designs on Obamacare.

If they use the budget reconciliation tactic, Senate Republicans won’t need to court Democratic support to pass their repeal — their four-seat majority will be enough. Any replacement law, though, will likely require 60 votes — meaning some Democratic votes — to pass. In the House, Democrats will be more marginalized, with virtually no way to block any repeal or replacement.

Democratic leadership is now focusing on winning over the public, and making any action against Obamacare as politically painful as possible.

Sen. Chuck Schumer, the Senate’s top Democrat, and Democratic House Leader Nancy Pelosi are organizing rallies and encouraging Democrats to hold events to whip up concern over what could happen to their constituents’ health insurance, including Medicare and Medicaid, if GOP repeal plans proceed.

On Wednesday, Obama traveled to the Capitol to meet with congressional Democrats, telling them to undertake a national organizing campaign to rally support for the law. He also called on the party to pressure moderate Republican senators who could potentially be persuaded to oppose the GOP plan.

At a press conference later, Democratic senators stood with Schumer, who proclaimed Trump and the GOP wanted to “make America sick again.” The Democratic leader vowed his caucus would not help Republicans replace the law.

Like their Republican counterparts, though, Democrats are not unified on an Obamacare strategy.

Sen. Al Franken, who sits on the Senate health panel, said in a statement to MinnPost that “dismantling the ACA is a dangerous and short-sighted move that will hurt millions of people,” and that the law should be built on and not ripped up.

Franken said the GOP has not offered up a viable replacement plan. “Republicans are playing political games with people’s lives, and the consequences could be disastrous,” he said.

First District Rep. Tim Walz agreed that the GOP pursuit a repeal without a replacement plan would be “catastrophic.” But unlike other Democrats, he’s willing to work with them on crafting that replacement.

The Mankato Democrat pushed back against the notion that Democrats should block the GOP’s efforts at every turn, and said he said the “make America sick again” messaging was the wrong way to go.

“If we say we’re going to obstruct, and say [Republicans] own this, then the public’s going to get mad at them, then we’re no better than they were,” he said.

Walz said he was going to try to look for places where like-minded Democrats and Republicans could work together to make meaningful reforms.

“If they can show some of these things are going to work, I’m willing to try on that,” he said. “Maybe they’re going to make some proposals in here that are going to fix some of these problems. I want to be there when they do.”

Explaining that his constituents are in “crisis mode” over high health care costs, Walz said any reform that works is worth Democratic support.

“If they want to call it Trumpcare and say it works and take credit for it, I’m fine with that,” Walz said. “If it actually works.”

Comments (14)

  1. Submitted by Dennis Litfin on 01/05/2017 - 11:49 am.

    The bottom line

    for Republicans is to not upset their “back pocket” friends…. The .Insurance Companies.

  2. Submitted by Joel Stegner on 01/05/2017 - 12:05 pm.

    30 million reasons

    It is actually very simple. Obamacare insured 30 million Americans, cutting the uninsured rate in half. If Republicans hadn’t opposed better access through Medicaid, it could easily have been 10 million more. Without this, we might compare even poorly to other countries in terms of our national health. As it is, our longevity has been in decline and failure to insure everyone is the root cause.

    What Republicans propose is totally irresponsible. It will probably leave most of these 30 million Americans without insurance, with rising disease and death rates the outcome.

    Do they have a plan to cover these people and avoid harming the industry? No. They say they need a few years to develop such a plan. Is there any reason we should trust them to keep their promise to replace? No.

    And let’s not forget that Ryan and others plan to privatize Medicare, Medicaid and the VA? Will all the people have coverage when this happens? No. They also plan these changes without having a plan to make sure people don’t lose coverage.

    But the thing is to remember, this involves huge profits to the investor class, and this is all about wealth, not health. Just think ahead – seniors without decent Medicare, left destitute by a privatized Social Security, forced to sell their homes to pay their medical bills. Guys like our incoming Treasury Secretary cashing in.

    For normal people a nightmare, but for the heartless who love to capitalize off of other’s misery, a real bonanza.

  3. Submitted by Frank Phelan on 01/05/2017 - 12:27 pm.

    This Or That

    There are two possibilities here. Either the GOP has no plan seven years after the ACA was passed. Or they do have a plan, they know Americans won’t like it.

    Either way, Americans need to take their country back from this radical minority.

  4. Submitted by Margaret Houlehan on 01/05/2017 - 12:29 pm.

    GOP

    Has had 7 years to craft a replacement. They don’t have one. Unless the tired triad of tort reform, interstate commerce, and tax credits can be counted.

  5. Submitted by Ray Schoch on 01/05/2017 - 09:41 pm.

    I’m with Joel

    The GOP has already had about 7 years on the calendar to devise a reasonable alternative to the ACA – which was, let us not forget, a Republican idea in the first place, coming from the Heritage Foundation, tried out in Massachusetts, where it was reasonably successful, and compromised in many ways to satisfy the insurance companies. The goal of those insurance companies is not your good health or mine, it’s to make money while paying their lobbyists and executives salaries that could, in at least some instances, be fairly labeled “obscene.” The fact that there is no viable replacement plan for the ACA after years of debate, and none on the immediate horizon, should tell anyone with a working brain that the health of the general public is not the primary consideration of Republican policy-makers and Congressional representatives. Joel is dead on-target in suggesting that this is a dispute revolving around wealth, not health.

    Some might hope that the GOP goes ahead and repeals the ACA without having a viable alternative, and they are then destroyed in the next election as a result. But some of those same people probably gave Donald Trump no chance to become President of the United States. Predicting the future is a risky business…

  6. Submitted by Tom Christensen on 01/05/2017 - 02:29 pm.

    When the Republicans repeal Obamacare

    It immediately becomes Trumpcare that they can rail about. Voters take note they will claim they have met their campaign promise of repealing Obamacare which makes the Republicans the owners no matter what the effective date of the repeal is. Trumpcare sounds so good. Now they will find out how easy it is to rail against something and how hard it is to fix it when they don’t having any idea of what to do about it. Good Luck Republicans all of America is waiting for your answer.

  7. Submitted by Sheila Ehrich on 01/05/2017 - 03:01 pm.

    No Plan

    Republicans, both nationally and in Minnesota, have spent the entire time Obamacare existed moaning and groaning about it. The have wasted time taking futile vote after futile vote to repeal the ACA.
    Have they spent any time researching and creating a replacement for it? NO, not one minute.Oh yes, Senators Hatch and Burr did work on The Patient CARE Act. But was this ever something that was presented to American voters as a serious replacement? Did Republicans ever run with this as a part of their platform, using it as an example that people should look at before voting for their Congresspeople?
    They’ve blustered and raged, but have not really ever presented any cohesive plan to the American public so that now when they finally have a legitimate chance to do something about it, they’re at a loss. All along they have said they want to include this, or drop that, or do something else in a different way. Never a cohesive plan available to all Americans – the public, business leaders, state governments, healthcare departments, healthcare insurers or the healthcare industry itself – doctors, hospitals. medical device makers, etc., etc., up for discussion by all.
    “Well, would this work for covering the millions of people who didn’t have healthcare before?” “Will states really take this aspect on? Or will only some states actually do it?” “Will what we’re proposing actually cost less? To the Federal Government? To state governments? To individuals?” “Will this work for employers? Big ones and little ones.”
    Without an opportunity to seriously look at Republican ideas and proposals, time to do the math, to consult with the”experts”, to consult the American people, Republicans in Congress are now going to try to do a hurry up job in time for the 2018 elections so they can all get re-elected, and then start fixing what their haste screwed up.
    And Republicans in Minnesota, I’m willing to bet good money, won’t have anything in place to help the hundreds of Minnesotans facing catastrophic healthcare costs and choices before the deadline.

  8. Submitted by Barbara Satin on 01/05/2017 - 03:08 pm.

    Since when?

    Since when does the American Enterprise Institute get moved from the extreme right to the “center-right” position? I’ve not seen any evidence of that shift. Are we all about normalizing such staunchly conservative viewpoints as the new centerpoint of political thought? Inept description!

  9. Submitted by RB Holbrook on 01/05/2017 - 05:15 pm.

    Something Else for the Boys to Consider

    According to a study released by the Commonwealth Fund and the GW University School of Public Health, “A repeal of key provisions of the Affordable Care Act (ACA) could lead to significant economic disruption and substantial job losses in every state, according to new research. In 2019 alone, 2.6 million people could lose their jobs. These losses could rise to nearly 3 million positions in health care and other sectors by the year 2021 . . .”

    http://us5.campaign-archive2.com/?u=8037a17ae97b2c79af6c8b136&id=7c58410c96&e=0f6b692671

  10. Submitted by Richard Adair on 01/05/2017 - 09:55 pm.

    Single Payer

    As Winston Churchill said, Americans do the right thing…after trying all the alternatives.

    Almost every other developed country achieves universal coverage at lower cost, by cutting out the insurance companies entirely. Eventually the market will force this upon us, as insurance costs continue to rise.

    • Submitted by Bill Willy on 01/06/2017 - 12:49 pm.

      Other developed countries

      United Kingdom: $4,000 per capita per year.

      Canada: $4,500 per person.

      Same basic thing in Australia, France, Germany, Italy, Japan, etc..

      United States: $9,000 per person per year.

      http://www.pgpf.org/chart-archive/0006_health-care-oecd

      And, as a bonus, worse health care outcomes for that extra $5,000: Shorter life spans and more chronic disease. One of the most disgraceful (not to mention deadly) examples of an inferior American product there’s ever been.

      More to it than getting the insurance industry out of health care, but they are definitely the lynch pin (or fog machine) that makes it possible to hide the massively inflated health care provider, drug and other “component vendor” costs, and getting them out of the game (or tightly throttled — like private sector companies in the electricity and water industries) would be a great place to start.

      Related to your Churchill comment, we would be wise to start making the transition to a better system ASAP so as to avoid the chaotic (not to mention deadly) fallout of what will most likely prove to be the inevitable burst of the bubblizing thing we’ve got going on now.

      As that $9,000 per person number indicates (when compared to the “baseline” cost those other countries provide), the current system is way “overvalued” and the reality is those in control and support of it have pushed things close to the maximum that “the traffic can bear.” Once that (magic) line is crossed (in any “sector”) things start imploding. Not because customers don’t need or want the product, but because they simply can’t afford it anymore: “Product providers” get too greedy (or “the market” runs away with itself) and they find they’ve priced themselves out of their own market.

      Next thing anyone knows, “Whoops!” Insurance companies are out of business (“organically”), hospitals are short of patients and long on beds, MRI machines, doctors, nurses and big (hospital expansion construction) loan payments, etc., etc., etc..

      The hope is we’ll be smart enough to not have to ride this particular “alternative” to that point of collapse in order to realize it’s not “the right thing.”

  11. Submitted by Bill Willy on 01/06/2017 - 11:38 am.

    Reality setting in?

    (This reminds me of that thing about how the most vehement anti-big government people say, “Get the government off my back, but whatever you do, do NOT mess with my Medicare or Social Security!”)

    The radio told me (while we were waiting for the just-turned-on heater to thaw the frozen well — coooooold last night) that Kaiser Health News says:

    “Only 20 Percent Of Americans Support Health Law Repeal Without Replacement Plan

    “The Republican strategy of repealing the Affordable Health Care Act before devising a replacement plan has the support of only one in five Americans, a poll released Friday finds.

    “The Kaiser Family Foundation survey also disclosed that shrinking the federal government’s involvement and spending in health care — the long-sought goal of House Speaker Paul Ryan and other Republican lawmakers — is less important to most Americans than is ensuring medical care is affordable and available . . .

    “Opponents [of Obamacare] have not coalesced behind the GOP’s two-stage plan of repealing the law immediately and then constructing a replacement. More people (28 percent) want a replacement plan announced before repealing the existing law than the share that says the law needs to be disassembled now (20 percent).”

    http://khn.org/news/only-20-of-americans-support-health-law-repeal-without-replacement-plan/

    From the horses mouth (a lot of interesting points there):

    “The Kaiser Health Tracking Poll: Health Care Priorities for 2017

    “Lowering Out-Of-Pocket Costs Is a Top Priority for Americans

    “When asked about a series of health care priorities for President-elect Trump and the next Congress to act on, repealing the ACA falls behind other health care priorities.

    “Two-thirds of the public (67 percent) say lowering the amount individuals pay for health care should be a ‘top priority’ for President-elect Trump and the next Congress.

    “This is followed by six in ten (61 percent) who say lowering the cost of prescription drugs should be a ‘top priority’ and

    “nearly half (45 percent) who say dealing with the prescription pain killer addiction epidemic should be a ‘top priority’ . . .

    “Americans’ Attitudes on the Future of Health Care in the U.S.

    Throughout the 2016 presidential election, it became clear that the two major political parties in the U.S. have competing views on the future of health care. When given two competing approaches to the future of health care,

    “six in ten Americans (62 percent) prefer ‘guaranteeing a certain level of health coverage and financial help for seniors and lower-income Americans, even if it means more federal health spending and a larger role for the federal government’ while

    “about one-third (31 percent) prefer “limiting federal health spending, decreasing the federal government’s role, and giving state governments and individuals more control over health insurance, even if this means some seniors and lower-income Americans would get less financial help than they do today.”

    http://kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-health-care-priorities-for-2017/

    Interesting. And not a bad sign. If the same sentiments apply across the board it MAY indicate the American people have more sense than the election seemed to indicate.

    If that’s the case the only question is, will the Republican (zealots) in Congress pay any attention . . . As they’re proven time and again lately, most of them don’t seem to care WHAT the majority of Americans say they want them to do.

    We’ll see.

  12. Submitted by Gerald Abrahamson on 01/07/2017 - 11:08 am.

    Short, sweet, and to the point

    Obamacare ends on Dec 31, 2017.
    Trumpcare begins on Jan 1, 2018.
    Just in time for the 2018 elections–if the voters who need care get in.

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