“Repeal and replace” has been the Republicans’ mantra on healthcare reform from virtually the moment Obamacare became law in 2010. House Republicans have voted for repeal, in whole or in part, dozens of times.
The second step, finding a replacement for Obamacare, has been more elusive. Republicans didn’t control the Senate until 2015. President Obama was never going to sign a bill rescinding the healthcare law that — good or ill, depending on your perspective — was his biggest domestic policy achievement and informally bore his name.
Republicans finally control both houses of Congress and the presidency. They won two midterm elections under Obama while running on repeal and replace. Now Donald Trump has seized the White House making that campaign promise.
It still won’t be easy. Much of the law can be repealed through the reconciliation process, which expedites legislation related to the budget and circumvents filibusters, which is how much of Obamacare passed the Senate in the first place. That means 51 votes. Republicans have 52.
Reconciliation could be used to repeal Obamacare’s taxes, insurance exchange subsidies and the Medicaid expansion. There is disagreement about whether the law’s insurance regulations could be repealed using this process; many experts don’t think so. Any aspects of repealing and replacing Obamacare that can’t be done through reconciliation would be subject to filibusters, which can be broken only by a three-fifths majority.
“I think people are realistic that we need 60 votes,” said Grace-Marie Turner, president of the conservative-leaning Galen Institute. “[Republicans] will never have it during this conference.” On replacement, she added, “They are going to work very hard to get Democrats on board.”
Anything that can’t pass via reconciliation would require eight Democratic votes. “The Democrats screwed up healthcare and we are trying to fix it,” said one GOP lawmaker. “If we can’t win that argument, good gracious.”
Republicans in Congress have never united around a single Obamacare replacement. What seemed like academic debates over various free-market healthcare reforms and gradual versus comprehensive change during the Obama administration has suddenly, and unexpectedly, taken on a new urgency.
That’s not to say Republicans didn’t plan ahead. The repeated Obamacare repeal votes while Obama was still president, derided by Democrats as time-wasting, redundant signaling to conservative voters, were partially designed to test legislative strategies for ultimately replacing the law.
Republicans agreed on the reconciliation strategy early. A rough consensus on broad strokes of replacement strategy formed among House Speaker Paul Ryan and relevant committee chairmen, including Rep. Tim Price, R-Ga., Ryan’s successor as House Budget Committee chairman and Trump’s nominee for secretary of health and human services.
“Healthcare will be better and will cost less when every part of Obamacare is gone,” said Rep. Jim Jordan, R-Ohio. “Everything we were told about Obamacare has been wrong.”
Four years have also made a big difference in Republican planning. Even though the public remains divided on Obamacare as premiums rise, insurers drop out of the exchanges and provider networks shrink, millions now get their health coverage through the law that they didn’t have before. And the Republican president who would sign repeal and oversee the administration of a replacement isn’t Mitt Romney, who was steeped in healthcare policy, but Trump, who is a newcomer to government.
In short, Republican congressional leaders must hold together members who all agree that the Obamacare status quo must end but have both tactical and substantive disagreements over how completely the law should be discarded, how quickly a replacement must follow repeal, whether to act in one big bill or piecemeal and how much of this can be done through reconciliation.
A sign of the trouble that could lie ahead came when Congress took the first step toward repeal. Both chambers passed a budget resolution including reconciliation instructions. No Democrats voted for it. Republican defections were minimal — just Sen. Rand Paul, R-Ky., and nine members of the House.
But the ideological makeup of the defectors is significant. Four of the “no” votes in the House came from centrists: Tom MacArthur of New Jersey, John Katko of New York, and Charlie Dent and Brian Fitzpatrick of Pennsylvania. Five came from staunch conservatives: Justin Amash of Michigan, Raul Labrador of Idaho, Thomas Massie of Kentucky, Walter Jones of North Carolina, and Tom McClintock of California.
The Republican leadership has passed legislation over the objections of these particular dissenters before, but it will become more challenging if their numbers grow. Centrists have publicly expressed concern about repealing Obamacare before arriving at a definite replacement plan.
Sen. Susan Collins, R-Maine, voted for the GOP budget resolution to get the repeal drive started. But that doesn’t mean she would necessarily vote for a repeal bill if the replacement remained ill-defined. “I’m hesitant to speculate on something that doesn’t exist,” she told the Portland Press Herald.
No conservative who bucked the party leaders objected to repealing Obamacare through reconciliation. They mostly opposed using an unbalanced budget blueprint with trillions in spending and debt as a vehicle for repeal. “[T]hese instructions can be included in ANY budget,” Amash tweeted.
The resolution’s defenders argue that it is merely a bareboned budget outlook to start the process that cannot yet assume the savings from Obamacare repeal and other reforms that Republicans plan to enact.
Nevertheless, concerns among conservative lawmakers and staffers on Capitol Hill are widespread that the unified Republican government won’t go far enough in rolling back Obamacare. One aide worried conservatives would get “rolled” in the process. Another pointed to Collins comments on the Senate floor regarding state prerogatives under her own proposal to replace Obamacare: “If they like the Affordable Care Act, they can keep the Affordable Care Act.” They mostly remain quiet in the hope that things will turn out better than they fear.
Anything pushed to 2018 and beyond, they believe, could unfold under much different political circumstances than exist today. The president’s party frequently experiences a setback in the midterm elections, even if the map looks favorable now.
While Rand Paul got significant attention for writing an op-ed calling for the immediate replacement of Obamacare, elsewhere in the piece he warned against the consequences of partial repeal.
“My fear is that if you leave part of Obamacare in place (the dictate that insurance companies must sell insurance to individuals with pre-existing conditions) then you will see an acceleration of adverse selection and ultimately mass bankruptcy of the healthcare insurance industry,” he wrote.
Paul later said that he had spoken to Trump, who agreed with him about the need for repealing and replacing at the same time. As a Republican president, Trump is a necessary prerequisite for Obamacare repeal. But he is the biggest wildcard of all, in many respects.
He frequently wades into public policy debates with tweets and off-the-cuff public remarks that are open to interpretation. “We’re going to have insurance for everybody,” he told the Washington Post. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”
Some fiscal conservatives view Trump’s comment through the prism of his past sympathy for single-payer healthcare and their skepticism of his commitment to limited government. Turner said she didn’t “see much daylight” between Trump’s position and Paul Ryan’s.
Trump has been consistent on some points, however. He wants to insure a comparable number of people without any gap in coverage. He wants the system to be simpler and to cost less. He wants competition but also doesn’t want deductibles to be so high that insurance is “useless.”
Whether Congress can actually deliver all of those is another question. Trump’s healthcare rhetoric frequently downplays the tradeoffs necessarily involved. Conservatives believe Price being confirmed as health and human services secretary is crucially important.
“His whole life has been preparation for this,” Turner said.
It should be noted that Obamacare wasn’t written at this point in Obama’s presidency and Democrats had important disagreements over healthcare reform themselves. These included differences over the individual mandate, the public option, the size of subsidies offered to those purchasing insurance through the exchanges, and eligibility requirements for those benefits.
At one point, it appeared that the whole bill might be stopped by a small group of pro-life but otherwise liberal Democrats in the House holding out for additional restrictions on abortion funding. Some were also concerned that excluding a public option would jeopardize progressive votes for Obamacare.
Yet Democrats had some advantages over the Republicans. Their majorities in both houses were much larger, including a filibuster-proof 60 Democratic votes in the Senate for a critical part of the Obamacare debate. Obama’s campaign healthcare plan was more detailed than Trump’s, even if the final product was substantially the handiwork of Congress. Negotiations between the White House and Congress did not take place over social media or in press conferences.
It still took more than a year for the Affordable Care Act to pass. Now it’s the Republicans’ turn to try their hand at healthcare reform. When it comes to charting a different course than Obamacare, they might not get another chance.
