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The Senate’s complicated plan to repeal Obamacare, explained by an expert on Congress

Leading Conservatives Attend 40th Annual CPAC Photo by Alex Wong/Getty Images

Senate Republicans took initial steps to repeal the Affordable Care Act Tuesday, using a process called budget reconciliation to start the process of gutting some of the health care law’s major provisions.

Update: Watch interview with President Obama on the future of Obamacare

The budget reconciliation process is complex, and not the normal way that Congress passes laws. It is a three-step process that starts with a budget resolution — essentially a list of spending targets for the coming years — and a set of instructions for how committees can hit those targets (in this case, by repealing Obamacare).

The reconciliation process constrains how much of Obamacare Republicans can dismantle; any changes they make need to affect the federal budget. Still, this allows them to attack some of the biggest parts of the Affordable Care Act, like tax credits for middle-income Americans to purchase coverage and the expansion of Medicaid to low-income Americans.

The reconciliation process is messy, and it’s constrained. But Republicans will use this more complex process because it has one big advantage: Legislation passed through the budget reconciliation process cannot be filibustered. So instead of coming up with a 60-vote majority, Republicans only need 51 votes to pass a reconciliation bill for repeal.

The whole process promises to be complex — so I called up Sarah Binder, an expert on congressional procedure at George Washington University, and had her explain it to me. We talked through the exact steps involved in budget reconciliation, how long it might take, and what obstacles Republicans could face. What follows is a transcript of our discussion, lightly edited for length and clarity.

Sarah Kliff

I understand that Republicans can use the budget reconciliation process to repeal big chunks of the Affordable Care Act that affect the budget, like the tax credits or the Medicaid expansion. What I don’t understand is, logistically, how that works. Can you walk me through the budget reconciliation process?

Sarah Binder

To understand reconciliation, we have to go two steps back. We have to start with the general congressional budget process.

A budget resolution is not law. It’s just a blueprint that the House and Senate adopt that sets out target levels of spending for different areas. You need the budget resolution because it provides the guidance for future appropriations bills for how much can be spent.

The budget resolution can include instructions to different committees. It comes out of the House and Senate Budget committees, and it can essentially say, “In order to hit these targets, we need you to come up with the savings on your turf.” When you’re talking about a reconciliation bill for health care, we’re talking about turning to committees like Senate Finance and Senate HELP [Health, Education, Labor, and Pension].

The reconciliation bill essentially tells these committees, “It’s time to do your part now, and send us some language on how you’re going to meet these targets.” And then the budget will be created to include those changes.

Sarah Kliff

So is it called reconciliation because the budget committee is essentially asking the other committees to reconcile the spending levels they want with actual policy?

Sarah Binder

Not really. The reason it’s called reconciliation is the original 1974 bill had Congress passing not one budget, but two. The second was essentially to clean up the first budget. It was supposed to be a budget bill to clean up the original documents.

Sarah Kliff

I know the Senate Budget Committee introduced their version of the budget resolution today, which is the first step here. And they do have a version of a repeal bill that they passed through reconciliation in 2015, one that Obama vetoed. Can they pull that bill off the shelf and move pretty quickly here?

Sarah Binder

The confusing part is that Republican senators are calling it the Obamacare repeal resolution, which it’s not. If you read through it, you’ll see a section asking the committees to come up with the savings from repealing Obamacare.

But Obamacare repeal doesn’t happen in a resolution. The resolution gives the instructions, and then after that happens you end up with an actual reconciliation bill.

I think what is taking time is that even though they have that bill on the shelf from 2015, this is a moment of reckoning. They need 51 votes, which was easy enough when they knew they wouldn’t be held accountable.

What do you do about Medicaid, now that you have Republican governors using the expansion, if all that comes crashing down? You have Sen. Lamar Alexander (R-TN) who wants to replace Obamacare at the same time as repeal, and Republicans certainly aren’t anywhere near that. The key stumbling block is that they’re accountable, and will be accountable for what goes into reconciliation.

Sarah Kliff

What’s your expectation at this point of how quickly or slowly the reconciliation process will proceed?

Sarah Binder

My sense is they’ve ironed out the budget resolution problems, and that should go quickly. I could imagine the Senate making their way through the resolution by the end of next week. They might wait until the day after the inauguration. Either way, the budget resolution should be done by time Trump is president.

In terms of the actual repeal, if they can do it, I think that is more 100 first days. That takes it into April or May. I don’t think this is something that gets taken care of in February.

Sarah Kliff

As you mentioned earlier, Republicans are calling this budget resolution an “Obamacare repeal resolution” even though it doesn’t actually do the work of repealing Obamacare — it just tells committees to come up with a plan for repealing Obamacare.

This raises the question for me: What happens if Republicans pass that resolution but aren’t able to get to 51 votes for the reconciliation bill? Does the whole thing kind of fizzle out? Are there any consequences?

Sarah Binder

That’s a really hard question. House Majority Leader Mitch McConnell (R-KY) is labeling the resolution as repeal, so that buys them some time. The whole process is complicated, so you start wondering, if they don’t do the reconciliation bill, will anyone know? If I’m a person who reads the news, will I really know? I would know if my Obamacare premiums change or I suddenly get a note about my insurance company backing out. Maybe I’m too cynical here, but I think a lot of the battle will be around messaging.

The assumption is they have no choice but to do repeal, but finding 51 votes is going to be tough. Everyone seems to think they will, by hook or crook, do it — but it’s a tough order.


Watch: Repealing Obamacare could change millions of lives