New year, new Congress, new healthcare reform battle. Republicans are making good on recent promises to address health reform early in 2017. In the same week that members of the 115th Congress took office, Republicans introduced a resolution budget that could pave the way for repeal of the Affordable Care Act (ACA). However, it looks like the path to health reform might be a rocky one.
Congressional Republicans move forward with repeal as expected
It's likely Republicans will attempt to use budget reconciliation to begin repeal of the ACA. This is a procedural tactic, explained in depth by Dylan Matthews for Vox, that allows legislation on spending and revenue to pass with a simple majority in the Senate, where Republicans hold 52 seats.
A budget resolution introduced by Sen. Mike Enzi (R-WY) last Tuesday is but the first step in what could be a very lengthy process. The resolution instructs committees in the Senate and House to draft reconciliation bills by January 27 in hopes a combined bill makes its way to president-elect Donald Trump's desk when he takes office to either veto or sign into law.
If all goes according to plan, the reconciliation will repeal parts of the ACA (only measures that affect government spending and revenue) and could delay its replacement. Reports have speculated anywhere from two to four years. More recently, Republicans have discussed delaying repeal until after the 2020 elections so at this point it's anyone's guess.
Repeal might be more difficult than initially believed
Reactions over last week's reconciliation could be described as a mixed bag. Democrats ramped up their messaging in support of the ACA and for Republicans to show them what the ACA could be replaced with. Last week in an interview with Vox, President Barack Obama called the repeal and delay strategy "reckless" and "irresponsible." He added if a Republican-led health reform works just as well as the ACA or better, he'd support it. However, he noted in the interview they have to show a plan first. On Monday, HHS Secretary Sylvia Mathews Burwell said Republicans should answer three fundamental questions about their ACA replacement coverage plan: Does it expand healthcare access to as many people? Does it maintain quality? Will it bend the cost curve in the right direction?
Government officials weren't the only ones who found the strategy peculiar. The American Medical Association (AMA) issued a statement against repeal and delay while Joseph Antos and James Capretta of the American Enterprise Institute, a conservative think tank, outlined why repeal and delay wouldn't be a great idea. The American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP) and American Congress of Obstetricians and Gynecologists (ACOG) issued a joint statement to condemn the strategy to repeal and delay. In addition,
Sens. Susan Collins (R-ME), Lamar Alexander (R-TN), and Bob Corker (R-TN) all expressed concern in December over repealing the ACA without a replacement, The Wall Street Journal reported. However, Corker, as Axios' Caitlin Owens reports, would vote yes on a repeal "if that's what leadership decides to put forward." In an op-ed published in Rare, Sen. Rand Paul (R-KY) wrote, “As we repeal Obamacare, we would be wise to vote on its replacement at the same time." Sen. Tom Cotton (R-AR) also voiced reservations in an interview with MSNBC last week.
In addition, five GOP senators introduced an amendment to the budget resolution Monday night that would extend the deadline for a repeal bill to be created from the original deadline of January 27 to March 3, Business Insider reported.
Absent any legislation to replace parts of the ACA, the Urban Institute estimated uninsured rates would rise to levels even worse than in the pre-ACA era. More uninsured patients could cause uncompensated care costs for providers to rise by $1.1 trillion over 10 years. An analysis by the Commonwealth Fund predicted that repeal would also have significant economic effect, leading to nearly 3 million job losses.
But again, it's anyone's guess. President-elect Trump said shortly after the election that the ACA could be “amended” rather than repealed outright. Kellyanne Conway, who will serve as a senior advisor to president-elect Trump after he takes office, said in an interview with MSNBC last week that “there are some pieces of merit in the current plan.” Vice president-elect Mike Pence recently told reporters the administration would quickly issue a series of executive orders on health reform, but did not offer details, The Hill reported. Sen. Paul said on Monday that Trump told him that a replacement should accompany repeal.
Trump himself has issued several vague statements about his current position on health reform, telling reporters that he is “not even a little bit” worried and that it will “all work out.”
So far, the battles have been drawn on which political party "owns the ACA" and will take the fall if a GOP-led healthcare reform doesn't work as planned. Trump got in on the action via Twitter to offer his thoughts on health reform last week:
Republicans must be careful in that the Dems own the failed ObamaCare disaster, with its poor coverage and massive premium increases......— Donald J. Trump (@realDonaldTrump) January 4, 2017
like the 116% hike in Arizona. Also, deductibles are so high that it is practically useless. Don't let the Schumer clowns out of this web...— Donald J. Trump (@realDonaldTrump) January 4, 2017
massive increases of ObamaCare will take place this year and Dems are to blame for the mess. It will fall of its own weight - be careful!— Donald J. Trump (@realDonaldTrump) January 4, 2017
While repeal seems likely, it is not a foregone conclusion. If just three Republican senators vote against their party, it could derail repeal efforts. Vox's Sarah Kliff also notes some GOP governors are actively trying to stymie ACA repeal.
Replacing the ACA will be even harder than repealing it
Republicans have been criticized for a failure to come up with a replacement plan to the ACA over the past several years that they have been calling to repeal and replace. However, to say Republicans do not have plans for health reform is not exactly accurate. There just hasn't been a good, clear consensus.
For example, the Republican Study Committee reintroduced last week a health reform bill previously proposed by Rep. Phil Roe (R-TN). The bill would allow interstate health insurance sales, provide tax credits for purchasing health coverage, and make changes to medical liability law. However, it is but one idea of many among the GOP health reform agenda.
Other legislators and conservative groups have also introduced health reform plans. House Speaker Paul Ryan (R-WI) released an outline for health reform last year that could serve as a guide to a Republican health reform plan. Dr. Tom Price, who will serve as HHS Secretary in the Trump administration, also introduced health reform legislation as a Republican congressman representing Georgia.
Some Democrats have stated they would be willing to work with Republicans to enact health reform. However, it would likely have to achieve many of the same goals as the ACA. “If they are having trouble, work with us not to repeal ACA, but to improve ACA,” Senate Minority Leader Chuck Schumer (D-NY) told Politico last week.
At the moment, the general public appears to be against plans to repeal without a replacement and possibly to repeal at all. Only 20% of respondents to a Kaiser Family Foundation poll supported an approach to repeal and delay while 28% said a vote to repeal should not occur until a replacement plan is ready and 47% said that no vote to repeal should occur at all.
Republican legislators have spent the better part of a decade railing against the ACA and calling for alternative replacement plan. With a majority in the Senate and the House and with President-elect Trump set to take office next week, now is their chance. However, if news from the past week is any indication, it will probably be more complicated than they expected. The next few weeks should provide a clearer picture of Republican health reform plans and how successful they are likely to be.