Donald Trump and GOP politicians repeatedly promised to repeal and replace the Affordable Care Act while on the campaign trail in 2016. Since the election, however, lawmakers have not proposed a congressional plan to replace Obamacare. Instead, the president, his staff and lawmakers have voiced a number of contradictory ideas about this hot-button issue. The meaning of the very words “repeal and replace” seems to change depending on who’s saying them.
For example, Counselor to the President Kellyanne Conway insists that no one will go without health coverage. The president himself has stated that the eventual repeal and replacement plan will lower deductibles while providing everyone with affordable insurance. He has also publicly opposed entitlement program cuts.
Some GOP lawmakers have concerns about these promises, particularly promises that tend to stray from traditional Republican views about healthcare funding. This may be one reason why after years of vowing to repeal Obamacare, GOP house members are unclear on which course of action to take. They’ve been debating among themselves about how to most effectively reach their own political goals, meet the public’s demands for affordable healthcare, and accommodate President Trump’s bold proclamations on the subject.
Repeal: Partial or Complete?
The word “repeal” brings with it the strong image of stripping away or tearing down, and while many Republicans used it in this way on the campaign trail, some members of congress have softened their tone since then. In fact, there are certain elements of the Affordable Care Act that should remain intact due to their popularity among the American people, such as:
- The ability of young adults to stay on their parents’ health plans until age 26
- Allowing people with pre-existing conditions to sign up without medical underwriting, thus keeping health insurance guaranteed-issue
- Funding methods that appear similar to those used under Obamacare, such as private Medicare plan spending cuts
Senate rules would also make full repeal of Obamacare difficult. If the GOP goes the route of using the budget reconciliation procedure, then they would only need a bare majority to get new legislation through Congress. If they don’t use this procedure, then they would have an uphill battle dealing with a Democratic filibuster. This reality makes President Trump’s call for immediate replacement after repeal even more of a challenge. Senate rules wouldn’t allow some aspects of the ACA to change under the reconciliation procedure. Instead, the GOP would have to remove portions of the existing healthcare law and wait until an unknown date in the future to enact new healthcare legislation.
Among likely targets for removal are the individual mandate and regulations that the GOP consider burdensome. However, rising insurance premiums and the mass exodus of health insurance companies from private marketplaces are unintended consequences that could be politically devastating. Supporters of repeal have repudiated these concerns, stating that lawmakers will find ways around igniting an insurance crisis that would cause millions of people to lose coverage.
Replacement: Immediate or Eventual?
Though President Trump has repeatedly told interviewers that he expects Obamacare to be repealed and replaced “simultaneously,” the current makeup of Congress and the complexity of healthcare legislation make that goal difficult to achieve. A few weeks ago, GOP lawmakers appeared to be working toward a transition period during which Obamacare exchanges would remain open to those seeking to purchase insurance while a replacement plan was devised. This complicated process would take months or even years to complete.
Tom Price and Paul Ryan have both nuanced their discussion of replacement by using words and phrases such as “concurrently” instead of “simultaneously” and assuring interviewers that they’re not interested in “pulling the rug out” from under the healthcare system – or the millions of people currently depending on ACA-subsidized plans. Lawmakers have also floated the idea of including some replacement ideas in any reconciliation legislation that’s put forward. Even after passing a reconciliation bill, Republicans also face the inevitable challenge of congressional negotiations with Democrats when the bill reaches that stage. Negotiations seem unlikely given the current hostility from both sides of the political spectrum.
Can a Replacement Plan Significantly Reduce Deductibles?
High deductibles are one of the most common complaints about the Affordable Care Act. Despite included coverage for some crucial preventive screenings, many individuals find the deductible levels they need to meet for most services under Obamacare unreasonably high.
GOP plans, by and large, don’t seek to limit deductibles. Instead, Republicans argue that by allowing insurance companies to sell some high-deductible, limited service plans, insurance premium rates will go down across the board because people will be given better choices. However, if they follow Trump’s directive to reduce deductibles while expanding coverage, the cost of insurance would have to increase. Such a plan may also increase government spending on healthcare subsidies.
Instead of reducing the cost of insurance to consumers through lowering deductibles, some GOP lawmakers have instead proposed that the problem of high costs be met through health savings accounts. Such accounts would allow individuals to save up money to spend on their healthcare in the future. Some have even suggested that these HSA accounts be subsidized by the government, and that consumers utilize these accounts to pay high deductibles. Whatever lengths GOP lawmakers may go to in order to reinterpret Trump’s promise, he has clearly stated that he wants to lower deductibles, which is not the same thing as providing people with health savings accounts.
Healthcare Coverage for Everyone?
Though Donald Trump has pledged to provide “insurance for everybody,” it’s unclear how the newest GOP replacement bill would achieve that goal. Universal healthcare coverage has traditionally been more of a Democrat promise than a Republican one, and some GOP lawmakers may balk at proposals that would impose even more government regulations in order to increase the number of insured individuals. Outcry from conservatives and liberals alike over the American Health Care Act, introduced by congressional Republicans on March 6, suggests that there is a lot of work to be done to put together an effective proposal.
Instead of parroting Trump’s rhetoric about insurance for everyone, some of the more cautious Republican lawmakers have instead shifted the message to providing “access” to healthcare instead. There’s a significant difference in terminology for a very good reason. Some in the GOP disagree with the federal government trying to provide universal health insurance coverage. Others, including Tom Price, have expressed agreement with Trump’s goal of increasing insurance coverage.
One Republican proposal from Susan Collins of Maine and Bill Cassidy of Louisiana would seek to expand coverage. It would allow states the choice of either retaining ACA plans or adopting plans that would provide basic insurance for all who chose not to opt out, or purchase their own upgraded plans. The basic plans wouldn’t include the list of benefits now included as “essential” in Obamacare plans. They also wouldn’t place any limit on costs.
What Happens to Medicaid?
President Trump has been emphatically in favor of leaving Social Security, Medicare and Medicaid benefits intact. He promised not to cut these important entitlement programs. This promise runs directly counter to statements from Paul Ryan and other GOP House members who would seek the semi-privatization of Medicare. But preserving Medicaid, Medicare and Social Security is a popular position regardless of political party. For the average American who pays into the system, these entitlement programs play a crucial role in healthcare, especially for the retirement crowd.
Despite the president’s promises, cuts could come in through the backdoor if the GOP healthcare plan reorganizes Medicaid funding using block grants. As it stands the federal government matches state Medicaid spending on at least a dollar-per-dollar basis, which can be particularly expensive in high-cost areas, such as rural areas with limited medical resources. The block grant system would give states a per-capita allotment of funding to be used as each state saw fit. It would save money, but it could also cut benefits. Republicans in favor of block grants argue that the system would encourage state innovation in Medicaid spending.
In order for the president and Congress to agree on a new healthcare legislation proposal, they’ll need to come to some sort of consensus about what “repeal and replace” really means. They will also have to reconcile their differences and come up with a plan that balances conservative principles with the reality of covering millions of Americans.