Going into the 2016 election, the general prospects for Obamacare under a new president seemed fairly straight forward: If a Republican won, the program as passed would be in jeopardy; if a Democrat won, it would remain intact.
But the quickly mounting failures of the law have made things far more complicated. Now it's looking like either Hillary Clinton or Donald Trump is going to enter the White House facing a crumbling individual insurance market — without sufficient support in Congress to address the problem. This will cause an early face-off between the president and Congress, not unlike the 2011 debt ceiling crisis or 2013 government shutdown.
Here's the basic problem. Obamacare has not signed up enough young and healthy individuals in its insurance exchanges to offset the cost of covering older and sicker enrollees. Insurers have been racking up billions of dollars in losses and have responded through a combination of hiking premiums, reducing the number of doctors and hospitals within their networks, or exiting markets altogether. These market exits have left consumers with fewer choices, and put even more pressure on the remaining insurers who now have to absorb yet more high-risk enrollees.
There's no reason to believe things are going to get better in 2017. Higher premiums, narrow networks and limited choices are likely to make Obamacare coverage an even less attractive product to younger and healthier Americans who don't have as urgent of a need for coverage. Furthermore, several programs within Obamacare meant to help insurers manage risk are set to expire at the end of this year.
As more and more insurers feel the heat from investors and exit markets and premiums grow beyond reach, the new president will face calls to do something to address the urgent crisis. But it's unlikely that the political conditions will make this possible.
Let's take the more likely scenario — that Clinton wins in November. (Note: Until Trump starts leading in polls in Pennsylvania, I will continue to view this as the more likely outcome). Clinton has already proposed a number of changes she would make to "build on" Obamacare. Generally speaking, these involve spending more money by increasing subsidies and creating a government-run plan, or public option, to compete with private insurance companies. Neither of these ideas face good prospects politically.
Her plans (or even less ambitious proposals meant to address the immediate crisis) will be vehemently opposed by Republicans, who won't be in the mood to "save" Obamacare. Under the best case scenario for Clinton — if the election is an absolute landslide — Democrats will have narrow majorities in the House and Senate. They will not have 60 votes in the Senate to overcome a filibuster, which would mean a bloody war over unleashing the "nuclear option" to kill the filibuster. Even if Democrats did that, however, Clinton would face problems in the House, where any Democratic takeover would involve winning relatively conservative districts in which representatives would not be eager to vote for legislation seen as an expansion of Obamacare.
In the less likely scenario that Trump is elected president, he'd also face considerable obstacles to responding to an Obamacare meltdown. If his pledges to pursue repealing and replacing the law are to be believed, he'd face unified opposition from Democrats, who would hammer him for the millions of Americans who would stand to lose coverage.
Passing such legislation would require either scrapping the filibuster or repealing as much as possible through a series of parliamentary maneuvers involving reconciliation. And even this assumes that Republicans, who have not litigated their differences on Obamacare alternatives, would swiftly rally around a specific plan.
Should Trump instead revert to his prior support for universal healthcare and try to cut a deal with Democrats to save Obamacare, he'd be starting his presidency at war with his own party.
A battle over healthcare dominated the first year of President Obama's administration. Thanks to the failures of his signature legislation, this is likely to be true for his successor.