In those days of Republican excitement after the party’s unexpected achievement of total electoral victory last November, GOP wonks and politicians quickly coalesced around a strategy for dealing with the long-promised repeal and replacement of the Affordable Care Act. The idea was that Congress would briskly repeal all or virtually all of the substructure of Obamacare, but the effective date of the repeal provisions would be put off until well into the future, in order (a) to reduce the immediate substantive and political impact of disrupting the existing system, and (b) to build pressure on Democrats to provide both congressional votes and “cover” for an Obamacare replacement. This strategy also gave Republicans a lot more time to reach agreement internally on a replacement plan.
Gradually, though, this strategy began to raise concerns among Republicans. For one thing, it slowly sank in that once Obamacare was repealed, insurers and providers might begin bailing out even if the repeal’s effective date was delayed. At the same time, conservatives began to worry that their “base” voters would view a delayed effective day for the repeal of Obamacare as a betrayal. Plus, giving their weak-kneed GOP colleagues an excuse for not implementing a rigorous new system until mañana might put off that fateful day indefinitely.
So the strategy of repealing and replacing Obamacare on separate tracks was already beginning to spring leaks. Then President-elect Donald Trump seemed to blow it up altogether, insisting in tweets, interviews, and his only post-election press conference that the repeal and replacement of Obamacare would be enacted “simultaneously,” or very nearly so. Emboldened by these comments, more and more GOP senators began expressing opposition to the strategy. It looked like the whole plan was in disarray, even though congressional leaders managed to keep every Republican except for Rand Paul in line for a mostly symbolic Senate vote last week.
It was more than a bit of a surprise, then, that in Wednesday’s confirmation hearing for incoming HHS secretary Tom Price, GOP Senator Lamar Alexander and Price twice chitchatted genially about a smooth transition to the new era as though we all understood that a “simultaneous” repeal and replacement meant simultaneous effective dates, not simultaneous action in Congress, as Trump and others had suggested. Simultaneous effective dates, somewhere down the road, were the essence of the original strategy before Trump intervened.
So what is happening here? Did Trump misspeak or change his mind about how this, the most important first step of his presidency, is going to go down? Are Alexander and Price pulling a fast one?
None of those questions were answered in this rushed hearing, with Democrats mostly focused on new evidence about Price’s potential violation of insider-trading laws. But a new and exhaustive piece by distinguished conservative health-care wonk Yuval Levin provides a peek beneath the hood of Republican planning. It appears that walking back Trump’s impulsive comments has been in the works practically from the moment the words appeared on his Twitter account.
After Rand Paul announced he had spoken with Trump, who agreed with him about making repeal and replace simultaneous, one congressional staffer suggested at a Capitol Hill meeting on health care that his boss could call Trump and get him to say the opposite. After Trump’s news conference last week, several members and staffers suggested (independently) that Trump must mean that repeal and replace should take effect simultaneously, rather than that they should be enacted simultaneously, in which case congressional Republicans were already on the same page as Trump.
The overall impression you get from reading Levin’s account of the development of GOP health-care policy is that the expressed views of the president-elect are not a big factor in what actually happens (indeed, he calls Trump’s assertion that his own administration is quietly cooking up its own health-care bill “a figment of his imagination”). So perhaps the original strategy is, in fact, back on track.
There’s something else Levin says repeatedly that should raise eyebrows everywhere: He claims Republicans are convinced they can do much of what’s essential to an Obamacare replacement plan via the budget reconciliation process — specifically, the 2018 budget bill, on tap for the spring and the summer.
If that’s true, there are two very important implications for the Obamacare repeal-and-replacement schedule: First, the replacement could be enacted this year (albeit not simultaneously with repeal), rather than two or three or four years down the road. Second, if the replacement is handled through reconciliation, there will be no need for any Democratic votes. That’s a very big deal. And if Trump and everyone else is finally on the same page, Republicans could move pretty quickly to kill and replace Obamacare, even if the day when it all comes down on America is delayed for long enough to mitigate the political damage.