House Speaker Paul Ryan has given a PowerPoint presentation and members of two committees have held epic overnight markup sessions as they try to get the House Republican leadership’s Obamacare proposal through the House of Representatives and over to the Senate.
But while Republicans are trying to keep up momentum in the face of growing opposition from House conservatives, Senate moderates, doctor and hospital interest groups and a host of others, it’s important to remember the effort we’re seeing on the bill currently being debated is the beginning stage of what will ultimately be a very long process. Here’s one road map for Obamacare repeal, but it’s worth noting there is very little room for error as the Republican leaders go looking for votes.
First step, repeal-plus
The House GOP is moving a repeal-plus plan, which seeks to repeal all it can via the budget rules and includes elements of replacement allowed by both the budget rules and the parliamentarian’s interpretation of them. This strategy was chosen to mollify wary moderates (and is generally opposed by conservatives who just want a straight repeal vote).
What this strategy allows is fulfilling the promise of repeal, with enough elements of replacement to keep a sustainable marketplace, at least according to Ryan.
Because the first leg of their effort is being done quickly through the budget reconciliation process, it is inoculated from a Democratic filibuster in the Senate, but that move limits how sweeping the repeal can be.
Second step, replace
Repeal-plus topples some major pillars of Obamacare, such as the individual mandate, but it’s not a complete fix. Republicans would still need to pass a replacement because lawmakers can’t do everything they want in the budget process.
After the repeal-plus process is complete, the House plans to start moving piecemeal bills that would not meet the reconciliation requirements and thus require 60 votes in the Senate. But these are also some of the most important parts of what Republicans want to do, like allowing insurers to sell policies that meet one state’s requirements in other states that might have stricter requirements.
This is where things get even more difficult for Republicans. Not only do they need to get their entire conference behind something in the Senate, they’ll also need to poach eight Democratic votes.
In full, it’s a multi-step, multi-bill process. The current American Health Care Act bill only requires 50 votes in the Senate (and a tie-break by Vice President Mike Pence). Subsequent bills require 60.
Meanwhile, as Congress does its work, Health and Human Services Secretary Tom Price will be focused on unilateral actions. The existing Affordable Care Act notes in more than 1,400 places that “the secretary shall” or “the secretary may.” Price, a doctor and former congressman, can to try to change the rules of Obamacare as Congress tries to get from repeal to replacement. But some of that power comes slowly following comment periods and rule-making processes.
This is the start of a process that could take a very long time.