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Today in Obamacare: the GOP has many questions, and few answers, on repeal

Bastiaan Slabbers/NurPhoto via Getty

When Donald Trump unexpectedly won the presidency and Republicans held on to Congress last November, many political observers assumed the Affordable Care Act was done for. Repealing the law had arguably been the party’s No. 1 political priority for more than six years, and the GOP had united to pass repeal through both houses of Congress in late 2015. The only reason their bill didn’t become law, it seemed, was that it was vetoed by President Obama, and soon that obstacle would be gone.

Three months later, the future no longer looks so certain, with many Republicans deeply uncertain about what exactly repeal should entail policy-wise, and worried about the political price they might pay for it.

Many congressional Republicans have made clear, both in public statements and in leaked audio from a recent GOP retreat obtained by the Washington Post, that they’re deeply worried about moving too quickly to get rid of Obamacare and being blamed for what may ensue. And the more this hesitancy grows, the more questions arise about whether anything will even pass at all.

What’s happened, essentially, is that the GOP has pivoted from an opposition party that could afford to grandstand and pander to an ideological base, knowing its plans would never become law, to a governing party that understands full well that its decisions could upend millions of people’s lives. (A phrase that has been heard around the Hill is that Republicans are “shooting with live bullets” now.)

Last month, I walked through the many, many procedural hurdles Republicans would have to overcome to get “repeal and replace” into law. And yet the policy and political challenges they face are, if anything, even tougher.

The GOP is quickly discovering that there is no magic “repeal and replace Obamacare” plan that will please everyone. Instead, any reform plan will create winners and losers. Getting rid of Obamacare’s loathed mandates could cause turmoil in the insurance markets. Cutting government spending on health care won’t help constituents complaining that their out-of-pocket costs are already too high. Eliminating Obamacare’s tax increases on the wealthy means there’s less money to pay for actually covering people.

At the beginning of this year, Republican leaders in Congress floated a “repeal and delay” strategy. The thinking was that they could quickly ram through a repeal bill via the 51-Senate-vote budget reconciliation process, but set it to go into effect in a few years, and craft a replacement (with would require Democratic Senate support) in the meantime. But then they got lots of feedback, including from Trump himself, that repealing Obamacare without a replacement was a recipe for disaster.

So now the idea is that Congress will tackle the repeal part and the replace part pretty close to “simultaneously.” That sounds all well and good, but crafting a full replacement will take time and likely won’t be able to be done through budget reconciliation rules, meaning at least eight Senate Democrats would have to be won over. And yet already, Trump is so toxic to Democrats that even senators in the deepest red states condemned his recent immigration order.

Another word we’ve started to hear of late is “piecemeal,” per Caitlin Owens. Under this strategy, some Republicans muse, they could pass multiple smaller reform bills addressing different parts of the market, rather than loading everything into one big legislative vehicle. But there’s a reason Democrats didn’t pursue a piecemeal strategy in 2009 — because that means you have to achieve the immensely difficult task of winning 60 Senate votes for major health reform not just one time, but many times.

All the while, premiums have been going up, enrollment numbers are looking weak, and insurers are pulling out of some marketplaces across the country. There are real problems with the health law that would seem to provide an impetus for quick congressional action. Insurer representatives said in a recent Senate committee hearing that they’d need some more certainty by March to make their decisions on where to sell individual market plans in 2018. The question is whether all this is sufficient to jolt Congress into action — or whether it will convince Republicans to punt major reform ever further down the road.

Today’s top health policy and politics reads

“Trump Administration May Use Executive Authority To Tweak Obamacare’s Rules”: “HHS has already submitted a proposal of new rules to OMB. And while officials have not said publicly what’s in that proposal, industry consultants and lobbyists told The Huffington Post that HHS has been considering the following three changes, among others. ... (1) Insurers would have more leeway to vary prices by age, so that premiums for the oldest customers could be 3.49 times as large as those for younger customers. ... (2) People who want to apply for coverage mid-year, outside of open enrollment, would have to provide documentation of a qualifying life change ― such as a divorce or lost job ― before coverage begins. ... (3) Insurers could cut off coverage for people who are more than 30 days late on premiums.” —Jonathan Cohn, Huffington Post

“Hospitals Fear Changes to Health Law, Press GOP on Revenue Concerns”: “Hospital executives are descending on Washington with a message: They are concerned about losing insured patients and revenue under any plan to dismantle or significantly alter the Affordable Care Act. In a flurry of recent meetings, the executives have told lawmakers they don’t want Americans to lose insurance under any alternative the Republicans devise for the Affordable Care Act. If that happens, however, hospitals say they want Congress to restore billions of dollars in federal funding they lost when the ACA took force.” —Melanie Evans, Wall Street Journal

“How Would Republican Plans for Medicaid Block Grants Actually Work?”: There’s no magic in how Congress reduces spending under a block grant mechanism. It just says it will do so, and leaves the hard decisions to others. It’s possible that some states will come up with solutions we haven’t been able to see before, and find a way to reduce spending without causing problems. If they can’t, though, they will have to make do with less, make the hard choices and face the brunt of the blame.” —Aaron Carroll, New York Times

“I’ve put my family on a health insurance experiment. It’s been a challenge”: “When a high-deductible plan became available through my employer, Harvard University, a couple years ago, I decided to enroll my family in it. If this is going to be a big national experiment, I thought that I, as a physician and a health policy scholar, ought to know what it’s like to live with this kind of health insurance. Debra, my wife, was not convinced...” —Ashish Jha, Stat News