The question of whether Republicans should repeal Obamacare appears settled. Vice President-elect Mike Pence was on Capitol Hill on Wednesday to rally his party’s lawmakers. Later in the day, the Senate voted 51-48 to begin debate on a budget resolution that would help pave the way for repeal of President Obama’s signature policy.
But don’t be fooled. The debate over whether to scrap the law is not yet over, and what appears to be merely a question of timing is about much more than that. As a result, Republicans will have to tread a careful path that balances a desire to abandon Obamacare as soon as possible with the need to respect the reality that the complexities of changing the system will persist well beyond any near-term bill signing ceremonies.
Of course, now that the end of Obamacare appears in sight, with the election of a Republican president and the party’s control of the Senate and the House, a chorus of voices is urging delay and caution. And it’s true that widespread, sudden disruption of existing health insurance arrangements could short-circuit a workable transition to more market-oriented and less Washington-centric health policy reforms. Hastily concocted political experiments on tens of millions of Americans could deliver unintended consequences.
Meanwhile, procedural and budgetary landmines on Capitol Hill also require careful planning, while holding together narrow working majorities — particularly in the Senate — as the Affordable Care Act is overturned will involve multiple compromises. Members must swallow hard and pull back from past rhetorical posturing.
But the reality is that such hurdles are by no means unique to Obamacare; they exist whenever any major changes in direction for complex national legislation are proposed. Even the Obama administration and its allies had to drastically revise the plans it envisioned in January 2009 and accept whatever it could get through Congress 15 months later (it then spent another six years trying to revise a deeply flawed law through often desperate means).
And it should also be remembered that many of the voices eager to recount how hard all this is will have other agendas — many want to preserve the status quo, not because it’s particularly valuable or popular, but because they claim it’s just too late and too hard to change it. (Not coincidentally, some of the loudest naysayers benefit more from maintaining than scrapping the current system).
Still, while the risk of ending up on the merry-go-round of ACA replacement proposals lacking sufficient support, depth, or effectiveness is real, there are risks posed by the opposite reaction: the desire for quick and simple repeal.
Congressional leaders are well aware that other unexpected issues suddenly can crowd out and capture the attention span and political capital needed to execute the challenges of health policy reform. And they also have a non-negotiable obligation to their voters to fulfill at least some portion of their longstanding campaign promises to repeal and (perhaps) replace (at least some parts of) Obamacare.
Ultimately, the current Congress and the incoming Trump administration cannot afford to walk away from this issue without being able to claim victory. To do so, they will likely start by taking one sizable leap for their supporters — repealing as much of the ACA as congressional procedures, budget scoring rules, and vote counts will allow in the first half of this year. As a result, some, but not all, of the repealed provisions will limp on for at least another year, if not longer.
In practice, that may mean something like the following moves:
— quick repeal of the individual and employer mandates for insurance coverage,
— delayed repeal of ACA taxes on the health care industry (at least until those sectors agree to “play ball” with the new majority’s transitional plans),
— continuation of insurance subsidies for 2017 that later become gradually revised (flatter and broader refundable tax credits) in future years, and
— accelerated reductions in Medicaid’s coverage expansion through per capita allotments to states.
The next daunting phase of reform — involving the regulatory side of Obamacare — will require larger, 60-vote majority compromises in the Senate that will leave just about all parties unhappy.
In other words, after a giant leap into the mostly unknown in the first half of 2017, some of the key political and policy facts on the ground will have changed. Republicans focused on maintaining their tenuous majority still face a steep and long climb. In this next stage, they will have to keep adjusting their tactics to the specific battles at hand involving replacement and transitional implementation. But one thing is certain — slipping backward is not an option for Republicans. Whatever comes next will require that they at least be able to declare victory.
