What Happens To Obamacare Now?

With Tuesday’s election of Donald Trump, the great white whale that animated conservative politics for the last half-decade is in Republicans’ sights. Come 2017, with control of the White House and both chambers, the GOP will have the votes for a major gutting of Obamacare, if not a full-scale repeal.

The question is how they’ll go after it and whether the policy and political complexity of dismantling the Affordable Care Act — even with broad GOP control of Washington — will still complicate Republicans’ path along the way.

Already, those on the party’s conservative wings, like Ted Cruz, are throwing down the gauntlet that repealing Obamacare should be an early priority of a Trump administration. But Trump himself has been all over the place on the issue. On the one hand, repealing Obamacare was a refrain of his stump act, particularly towards the end of the campaign. But when asked how he would replace it, Trump would describe ideas that sounded vaguely like Obamacare.

And that’s just the beginning of the mess.

First, Republicans won’t be able to repeal the law full-stop. Without 60 votes to overcome a Senate filibuster, they will have to depend on the budget reconciliation process, which only requires 50 votes to strip out the budgetary aspects of the law. This was the template for a repeal bill Republicans passed last January, before its demise by President Obama’s veto pen. The exercise was described as a “test run” for just the scenario — a GOP House, Senate and White House –they’ll find themselves in two months.

“This Congress, this House majority, this Senate majority, has already demonstrated and proven we’re able to pass that legislation and put it on a president’s desk,” House Speaker Paul Ryan said at a press conference Wednesday morning, when asked about the prospect of an Obamacare repeal.

In that bill, the law’s Medicaid expansion program, insurance subsidies, its tax penalty mandate, and other taxes to to fund its other programs would be scrapped. But its non-budgetary provisions, like its requirements that insurers don’t drop consumers on the basis of pre-existing condition and that they allow young people to stay on their parents plan until they’re 26, would continue to stand. The irony of this bootleg repeal method is that Republicans would likely inflict even more damage to Americans’ insurance rates than a full scale repeal. Such an approach would leave some of law’s requirements in place without the sticks and carrots to make them work, and the whole system could be kicked even further out of order.

“That means that it could lead to more people losing health insurance than the estimated 20 million who have gained it under the law,” the New York Times’ Margot Sanger-Katz wrote Wednesday.

From a political perspective, that path is laden with obstacles as well. When GOP lawmakers were debating the bill, some Republicans in purple states raised concerns of scrapping the Medicaid expansion provisions that benefited thousands of their constituents. Understanding that Obama’s veto pen meant the political fallout wouldn’t have to be dealt with, at least not right away, they eventually jumped on board.

Jason Pye, a spokesperson for the conservative activist group FreedomWorks, which will be among those leading the charge on an Obamacare repeal, said that he expected Republicans to use the reconciliation bill, but advised that they have a replacement plan queued up as they moved forward with it.

“The smart thing would be to have an alternative ready to go as soon as the repeal bill passes and have something waiting” to replace Obamacare, Pye told TPM Wednesday morning.

That, however, introduces its own set of complications. The party, while in lockstep on an ACA repeal, is in stark disagreement on how to replace it and on the broader question of the government’s role in health insurance industry.

A microcosm of the philosophical range among Republicans could be found in their inability to land on a back-up plan in 2015 had the Supreme Court invalidate a key provision in Obamacare that provided subsidies for certain ACA marketplace consumers. The simple question of whether the government should do anything to blunt the impact on consumers deeply divided the caucus.

On replacing Obamacare, some GOP lawmakers have introduced plans that showed few signs of earning a consensus, while the ambiguous Better Way agenda trumpeted by Ryan offered not enough detail to truly assess its consequences.

Add to this chaos the fact that the ACA, and health care policy at large, has a broad spectrum of moneyed interests. Insurers, hospitals, drug companies and even financial firms stand to gain or lose a lot, depending on what Republicans do, and in the six years of Obamacare’s existence, have become deeply invested in its implementation. That’s not to say these influential groups would break evenly one way or the other on whether it should be repealed in the first place. Knowing that some sort of repeal effort is inevitable, their calculus may be to guide that process in a direction that does the least damage to their interests.

America’s Health Insurance Plans, the top trade group for health insurers, had only a vague statement to offer Wednesday on Obamacare’s prospects in light of Trump’s victory. The group promised to “work across the aisle – with every policymaker and the new administration – to find solutions that deliver affordable coverage and high-quality care for everyone.”

No matter how this all plays out, Republicans will be under enormous political pressure to move quickly against Obamacare, given that after three straight campaign cycles of promising to repeal it, voters have finally given them the opportunity to do so. It’s almost certain the ACA of now will emerge from the next four years badly beaten and bruised, if not completely dead.