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“Repeal and delay”: McConnell’s new, risky health care plan, explained

GOP Senators Continue Work On Revised Health Care Bill Photo by Win McNamee/Getty Images

In the wake of a failed bill to replace Obamacare, Senate Majority Leader Mitch McConnell is proposing a new plan: Repeal Obamacare — and set up a deadline, two years in the future, to replace it.

The idea has a certain logic. Republicans can quickly make good on their promise to repeal Obamacare and then get to the hard work of actually figuring out what should come next.

And it has precedent. Congress passed a clean Obamacare repeal bill in 2015, which President Obama quickly vetoed. Senators could presumably return to that bill and pass it a second time — although this time, they’d expect Trump to turn the bill into law.

But here’s the problem: In practice, the act of repealing Obamacare, even with a two-year delay for a replacement, would set off a catastrophic reaction across the health care system. A successful repeal vote would drive insurers out of Obamacare’s exchanges, leading to collapsing marketplaces across the country, and Republicans would bear all the blame.

This is not a new and clever argument I’m making. Republican senators flirted with the idea of repeal and delay back in January but rejected it after thinking through the consequences.

“Why would we put off for three years doing what we know we have to do?” Sen. Bob Corker (R-TN) told reporters at the time.

Outside analysts on both sides of the aisle warn that the approach could cause chaos, by encouraging health plans to flee Obamacare’s marketplaces and leave current enrollees with few to no health insurance options.

“Repeal and delay would be a terrible policy to adopt,” says former Congressional Budget Office Director Doug Elmendorf. “Passing it will badly damage the health care system. It would make far more sense to wait until the actual alternative is written.”

The absence of an “actual alternative” speaks to the other problem with repeal and delay. McConnell is turning to this strategy because his effort to craft and pass a replacement plan is failing. But if it’s failing now, why would it succeed in two years — two years in which the politics of health care would only have gotten more gruesome for Republicans, and during which Democrats will be using the issue to gain ground in the midterms?

Why McConnell now thinks repeal and delay is a good strategy

Republicans have, for six years now, run campaigns where they promise to demolish the health care law and pass something else in its place. The problem is, Republicans gained control of Washington in the 2016 election — and the “something else” wasn’t quite ready.

Republicans quickly put together plans to replace the Affordable Care Act but have struggled to coalesce around them. The House passed its American Health Care Act in May, which would leave 23 million Americans without coverage and remains unpopular with the public. The Senate began debating its Better Care Reconciliation Act in June, but McConnell has been unable to win the support of the 50 senators needed to move the proposal forward. Both plans have proven broadly unpopular.

On Monday night, after defections from four senators left him without the votes to even begin debate on his replacement plan, McConnell conceded Obamacare would remain the law of the land for the time being.

“It is now apparent that the effort to repeal and immediately replace the failure of Obamacare will not be successful,” the majority leader said in a statement.

McConnell then pivoted to the idea of repeal and delay: holding a clean Obamacare repeal vote this week and setting a deadline for two years in the future. “In the coming days,” he announced Monday night, “the Senate will take up the bill ... a majority of the Senate has already supported in 2015: a repeal of Obamacare with a two-year delay to provide for a state transition period.”

“Repeal and delay would be a terrible policy to adopt”

Obamacare repeal and delay is a risky strategy that experts expect would cause millions to lose coverage.

The biggest risk, of course, is that Republicans wouldn’t come up with a replacement plan within two years and Obamacare repeal would come into effect. If this happened, the Congressional Budget Office estimates that 32 million Americans would lose coverage as the Medicaid expansion and private health insurance subsidies both disappear. The CBO also projects that premiums in the individual market would double.

There is not much about the past six months’ debate that suggests Republicans would be able to come up with a replacement plan within two years. We’ve seen deep divides between more moderate senators who oppose significant Medicaid cuts and more conservative members who support such policy changes.

Repeal and delay would, in the short term, wreak havoc on the Obamacare marketplaces. These platforms depend on private insurers showing up to sell coverage — and even before the threat of repeal, that was a struggle. The marketplace lost many plans this year as the people buying coverage turned out to be sicker and older than insurers initially expected.

Even before the election, Obamacare’s marketplaces were struggling. There were serious discussions about whether some counties could retain enough insurers to continue to function properly, particularly in rural areas with small populations.

Republican repeal efforts have made insurance plans even more hesitant to sell coverage in 2018. There are currently 38 counties where zero plans have decided join the marketplace next year.

Putting an expiration date on the marketplaces will only make insurers more reticent to stay in the market — and more likely to drop out.

Insurers need to make decisions far in advance about whether they’ll sell on the marketplaces. They will need to tell the Department of Health and Human Services this fall whether they plan to sell coverage in 2018. If Obamacare has been officially repealed, and the future is uncertainty and chaos, why would they bother to participate in the program?

When Congress first considered the repeal-and-delay effort in January, I spoke with half a dozen experts from both sides of the aisle about the expected effects. They roundly expected that repeal and delay would lead to Americans losing insurance coverage during the delay period — either because premiums spike so high that they would be unaffordable or because some areas of the country have no health insurers that want to sell plans.

“I expect the Congressional Budget Office will show a loss of coverage because of repeal and delay,” says Elmendorf, who now serves as dean of the Harvard Kennedy School of Government. He said it’s very difficult at this point to guess how large that loss of coverage would be, given how unprecedented this type of policy decision would be.

“CBO will have to apply a lot of judgment because we don’t have any clear, comparable situation in the past that I’m aware of,” he says.

Some Republicans have become wary of the repeal-and-delay strategy — and that demonstrates the shifting politics of the Affordable Care Act

Republican senators from both sides of the aisle have historically been quite skeptical of the repeal-and-delay strategy. When the idea came up in the winter, here are some of the things they said about it:

  • Sen. Lamar Alexander (R-TN) pressed party leadership in early December to do repeal and replace at the same time.
  • Sen. Rand Paul (R-KY) wrote an op-ed on January 3 arguing against repeal and delay, and he was the sole Republican senator to vote against the initial step the Senate took in January to start the repeal process.
  • Sen. Susan Collins (R-ME) told a local newspaper in January she agrees with Alexander’s push to focus on replacement before repeal.
  • Sen. Bob Corker (R-TN) told reporters in December, “Why would we put off for three years doing what we know we have to do?”

We don’t know whether these senators would come around to the idea now that they’ve struggled to pass a replacement bill.

Obamacare was an easy target for campaign ads and stump speeches. But the reason you’re seeing intraparty Republican strife over repeal and delay is that legislators are now confronting what it would mean to disrupt health coverage for millions of Americans. Repeal and delay doesn’t solve the problem, or even put it off. It makes it worse.

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