By Chuck Raasch
WASHINGTON -- Campaigning to repeal and replace Obamacare was the easy part. Now comes the hard slog of legislative reality.
With some Republicans talking publicly and privately about a phase-out period of two years or more, and others — including Missouri’s Sen. Roy Blunt — expressing a desire to keep parts of the 2010 health care reform, the first order of business for Congress in January may turn out to be one of the hardest of the Trump years.
“This is a huge undertaking, and it is going to be extremely difficult, politically, on a number of levels,” said James Capretta, an expert in health care policy at the American Enterprise Institute, and formerly budget and health care adviser to congressional Republicans and former President George W. Bush.
Senate Republican Leader Mitch McConnell says that a repeal of Obamacare, along with swift appointment of President-elect Donald Trump’s Cabinet appointments, will be the first things his Senate will undertake in the New Year.
Asked whether a major overhaul of Medicare, whose financial future is threatened by an aging population, will be part of that initial work, McConnell was noncommittal.
“I am not going to speculate on what the agenda may be on a variety of different issues next year,” McConnell said. “I can tell you where we are going to start: with the process to replace and repeal Obamacare.”
Price battle looms
A proxy battle over that assault will be the nomination hearings of Rep. Tom Price, R-Ga., for Health and Human Services secretary. Price, an orthopedic surgeon before he came to Congress, authored a replacement for Obamacare as Republicans fought unsuccessfully for six years to take down President Barack Obama’s most comprehensive legislative achievement.
Democrats say they fear Price’s history shows he will push for privatizing Medicare as part of any long-term health care overhaul.
“There will be issues where we can work with the president-elect and his party,” said Sen. Chuck Schumer, D-N.Y., who will be the Democrats’ Senate leader. “Privatizing Medicare is certainly not one of those issues.”
Democrats say it’s one thing to campaign against a law, but another entirely to replace it when it has parts that the public likes. They point to provisions preventing insurers from denying coverage to people with pre-existing conditions and allowing children up to age 26 to stay on their parents’ health plan.
Democrats also point out that many of the provisions are complex and interconnected, and that repealing without something to replace them could create even worse problems than the Republicans say the law has created.
The pre-existing conditions aspect works, in theory, because of the individual mandate that brings younger, healthier people into the system, the law’s proponents say. Philosophically, Republicans want to get rid of that and replace it with financial incentives tied to some of the more favorable parts of the current law.
“If President-elect Trump sticks with the premise that insurance companies should not be allowed to discriminate against people with pre-existing conditions, that is certainly one of the elements of the Affordable Care Act,” said Sen. Dick Durbin, D-Ill. “But it also brings with it the requirement that you have a pool of people being insured that doesn’t include those pre-existing conditions. So when they get down to the real world of writing this bill, they are going to find some real challenges.”
“As we work to repeal and replace Obamacare, it is important that we work together to pass policy that will achieve many of the goals that we all share, such as ensuring patients with pre-existing conditions have access to health care,” Blunt said.
“I will also continue to advocate for children being able to stay on their parents’ insurance until they are 26, which is something I introduced in the House, “ Blunt said. “Congress will vote early next year on Obamacare, but the overall reform is not something that we can put a hard time frame on because it needs to be done right.”
One of the most consequential questions facing Blunt and Republicans is how necessary they will see Democratic votes as a predicate for any kind of reform, and how that reality will shape both the process and the final product.
Republicans relentlessly attacked Democrats for passing Obamacare in 2010 without a single Republican vote, thereby drawing a clear political divide in successive elections as some promises about the law did not play out as intended, and became unpopular. If Republicans reverse course without at least some Democratic votes, and if the repeal and replace process is as messy as some fear, the blame game would take a 180-degree switch in coming elections.
‘A recipe for real chaos’
Capretta, the health care expert, said one of the biggest challenges in a Senate the GOP controls by just two seats will be to convince nervous Republican senators to vote to repeal the law without having a logical replacement. He said he has talked with some of them but would not name them since they have not publicly disclosed their concerns.
“My gut tells me that this idea of a quick, clean, repeal-only bill will falter, at which point there will be a longer, months-long slog of, ‘How do we repeal sections of it and replace it with things we like better?’” Capretta said.
He predicts that, despite his advice, congressional Republicans will put off a major overhaul of Medicare, content with knowing that many changes they favor can be done administratively by the Trump administration.
Capretta said he would not be surprised to see the state-exchange networks created under the law remain, albeit with a more nationally competitive marketplace that would make it easier for residents of one state to get insurance from a provider in another.
“It’s an infrastructure that is kind of useful,” Capretta said of HealthCare.gov.
He said some Republicans recognize that repealing the individual mandate and the mandated taxes on employees while leaving things like the pre-existing conditions provision in place “is a recipe for real chaos.
“So I think they may have to, by necessity, delay everything that they want to repeal for a couple of years, if that is what their route is, and that may include (retaining) the individual mandate for a couple of years while they sort out what would replace it,” Capretta said.
Dr. Merrill Matthews, a resident scholar at the policy research organization Institute for Policy Innovation in Dallas, says clues for possible Republican replacements are in the House bill Price wrote.
The plan included expanded tax credits for those who do not have coverage from an employer and a major expansion of tax-free, health care spending accounts for everyone, Matthews said.