The Republican plan to eliminate Obamacare is to repeal the law, delay for a long time, and then, allegedly, create a replacement for it. The replacement is the hardest part of the equation, since Republicans will never support a reform that provides enough coverage to satisfy most Americans. The repeal part is easier. But it’s still not easy at all. And as Trump’s government takes shape, signs are already popping up everywhere that the GOP is reconsidering its plan to repeal the law quicky.
Repeal and delay is a plan that sounds attractive in theory, but presents Republicans with enormous political risks. If they pass a law to repeal Obamacare on a time-delayed basis, with no replacement in hand, stakeholders like insurers and hospitals will face huge financial losses, and it will probably disrupt coverage for millions of their customers. The only way to prevent such a catastrophe would be to shore up the system until they can devise a replacement. But patching up Obamacare would enrage some conservatives who oppose “bailouts” for the insurance industry, and would also have the side effect of proving Obamacare can work, making it harder to repeal. Republicans, like Colonel Nicholson in Bridge on the River Kwai, would have built the thing they had set out to destroy.
That Democrats will oppose repeal-and-delay is obvious. But over the last several days, a growing number of Republican, or Republican-friendly, voices have turned against it as well. James Capretta and Joseph Antos of the conservative American Enterprise Institute warn in the journal Health Affairs, “The most likely end result of ‘repeal and delay’ would be less secure insurance for many Americans, procrastination by political leaders who will delay taking any proactive steps as long as possible, and ultimately no discernible movement toward a real marketplace for either insurance or medical services.” The American Medical Association, an influential lobby representing an affluent constituency, and which endorsed Trump’s right-wing nomination to lead the Department of Health and Human Services, issued a statement opposing repeal-and-delay. Republicans like John McCain, Newt Gingrich, and even Rand Paul have urged their party not to tear down Obamacare without a replacement. (“If Congress fails to vote on a replacement at the same time as repeal, the repealers risk assuming the blame for the continued unraveling of Obamacare,” writes Paul.)
Trump himself, somewhat elliptically, echoes these cautions. In a series of tweets this morning, the president-elect — while calling Obamacare a disaster — warns that repealing it will make Republicans responsible for the chaos that ensues:
Republicans need 50 of their 52 Senators to support a repeal bill, plus of course the President’s signature, to pass repeal. Neither of those seems certain right now.
What’s the alternative? There’s no attractive option at hand. A key problem is that Obamacare can be defunded with 50 Republican Senate votes, but replacing it means rewriting the insurance regulations in the law, which needs 60 Senate votes, or at least 8 Democrats. Republicans could try to negotiate with Democrats on changes to the law that would make it more Republican-friendly — which means taxing rich people less, skimpier subsidies to the poor and sick, and cheaper premiums for the rich and healthy — that they could call a “replacement” for Obamacare. Democrats would not like any of these changes, but perhaps if their scale was small enough, they could accept them in return for a truce in the health-care wars that left most of the law’s achievements in place. Or they could stick with their plan to repeal the law, delay its effect, patch up the system enough to keep it afloat, and leave it for another day.
There’s no course of action that avoids taking on high levels of political risk. The Republicans have made impossible promises on Obamacare — providing more coverage than Obamacare without anybody having to pay for it — and they are figuring out that the path they take from that promise leads into a political quagmire.