Under President Trump, Repealing & Replacing Obamacare Will Be Harder Than It Looks

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Republican presidential candidate Donald Trump gestures as he walks off the stage following a campaign rally late Saturday, Nov. 5, 2016, in Denver. (AP Photo/David Zalubowski)

After it became clear that Donald Trump had defeated Hillary Clinton for President, a lot of the news coverage focused on one of Donald Trump’s key policy promises: that, “on day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare.” But fully repealing Obamacare—let alone replacing it with better reforms—will be far more difficult than a lot of observers believe.

Full repeal requires overcoming a Senate filibuster

To start, full repeal of Obamacare can’t happen unless 60 U.S. senators vote for it, thanks to the filibuster. And there aren’t 60 votes in the Senate for full repeal; if advocates are lucky, there will be 52. (In 2017, Republicans will control either 51 or 52 Senate seats, depending on the outcome of a runoff in Louisiana.)

Republicans could, in theory, get rid of the filibuster, but Mitch McConnell and others have routine expressed opposition to that idea. (And that’s a shame.)

Partial repeal would keep most Obamacare regulations in place

The best that Republicans can do is to pass a partial repeal of Obamacare using the reconciliation process, which only requires 51 votes. Republicans did this in January, when they sent to President Obama’s desk the Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015.

That bill would have repealed Obamacare’s tax hikes, Medicaid expansion, and insurance exchange subsidies, affecting more than 15 million enrollees. That’s a big deal, because it affects $2 trillion of spending over the next decade.

But critically, the partial repeal bill does not get rid of Obamacare’s tens of thousands of pages of insurance regulations, the regulations that are responsible for the law’s drastic premium hikes.

It may be that those premium hikes helped elect Donald Trump on Tuesday. So it would be ironic if that’s the part of Obamacare that a President Trump couldn’t repeal.

Republicans totally disagree on how to replace Obamacare

The path only gets harder from there. Republicans have not arrived at anything resembling a consensus as to how to replace Obamacare.

Donald Trump and I have something in common on this subject: we both support universal coverage. “Everybody’s got to be covered,” Trump told 60 Minutes’ Scott Pelley in September 2015. “The government’s gonna pay for it.”

There are different ways to achieve universal coverage, however. Trump has expressed admiration for single-payer and socialized health care. In the second edition of Transcending Obamacare, I describe how Congress could transition people to a patient-centered, market-based approach to universal coverage.

House Speaker Paul Ryan has proposed a plan he calls “A Better Way,” which would be much more market-oriented than Obamacare, but could lead to more people being uninsured than there are today.

That plan has been attacked by other Republicans, who believe that any effort to subsidize coverage for the uninsured amounts to “Obamacare Lite.”

These disagreements came into full force when Republicans were at loggerheads on how to provide transitional assistance to Obamacare enrollees in the event that the Supreme Court ruled the right way in the King v. Burwell Obamacare case. The justices went the other way, however, sparing Republicans the need to patch up the hole.

The Republican House has at times proven incapable of passing basic legislation. Are they somehow going to come together on health reform, with an even slimmer majority?

The path to a successful Obamacare replacement

Having said all that, it is definitely possible for the GOP to repeal and replace Obamacare. The sequence would go something like this:

  • Partially repeal Obamacare via reconciliation, with the subsidies expiring in 2019.
  • Get Republicans to agree on a pathway to market-based universal coverage that reduces, instead of increasing, the federal role in health care.
  • Use the two-year window to achieve market-based universal coverage by repealing the ACA’s premium-hiking regulations, replacing it with a system of means-tested tax credits.
  • There are likely to be 60 votes for the Obamacare replacement under this scenario, because once Obamacare’s subsidies have been repealed, Republicans will have negotiating leverage with Democrats who would prefer a more statist approach.

    The will is there. On the day after the election, Senate Majority Leader Mitch McConnell (R., Ky.) said that repealing Obamacare is “pretty high on our agenda, as you know.” House Speaker Ryan added, “This Congress, this House majority, this Senate majority has already demonstrated and proven that we’re able to pass that [partial repeal] legislation and put it on the President’s desk.”

    But it’s incredibly important to remember that as Republicans repeal Obamacare, the media will be filled with stories about Americans with cancer and multiple sclerosis who are losing their coverage. Republicans will not be able to survive the PR onslaught unless their own plan covers at least as many people as Obamacare does.

    Will they be smart enough to put together such a plan? Time will tell.

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