Republicans Have An Obamacare ‘Replacement’ Problem


Tierney Sneed and Caitlin MacNeal contributed to this report.

Their slogan is “repeal and replace,” but as Republicans debate their vision for an Obamacare alternative, they are beginning to see that options are limited, the politics are fraught and the clock is already ticking into President Donald Trump’s first 100 days.

Republicans are at a crossroads with their replacement. Either they can pass a repeal bill in the coming weeks and hope Democrats – facing political pressure in red states – will assist them later with a replacement. Or Republicans can go it alone on a replacement, relying heavily on administrative actions and limited procedural tactics to partially overhaul America’s health care system. At the moment, they appear to betting they can come up with an adequate replacement even if Democrats stand in their way.

“I don’t think it’s going to happen immediately. It’s going to take longer than some figured,” said Sen. Jeff Flake (R-AZ). “It’s complex, but I think we will.”

On Capitol Hill, Republicans are bracing to charge ahead at this point along party lines even if that means their replacement plan becomes limited by what they can tuck into a reconciliation package. Reconciliation only requires 51 votes to pass in the Senate, but the process only allows Republicans to make changes to Obamacare that have budgetary effects. It severely limits their ability to make the kind of sweeping regulatory changes they’ve talked about for seven years.

Republicans have long warned they wouldn’t replace Obamacare with their own 3,000-page bill, but constituents who’ve heard the refrain of “repeal and replace” for so long may be surprised by how limited in scope the GOP replacement bill ends up being now.

“I used to say that if they’re expecting somebody to roll a wheelbarrow in with McConnell-Care on it to replace Obamacare, that they’re gonna be disappointed,” Sen. Lamar Alexander (R-TN), said after the presidential election.

What Republican members told TPM they believe is afoot is a three-part plan with an option for a fourth step. First, Republicans will repeal as much of the the Affordable Care Act as possible using reconciliation. Second, they will try to put as many replacement provisions in the repeal bill as possible. (Replacement provisions could range from implementing high-risk pools to making sure people with pre-existing conditions have coverage to block granting Medicaid to creating health savings accounts. Those provisions are limited, and health care policy experts have argued they likely wouldn’t drive down costs.) Third, Republicans would turn to the Trump administration to make regulatory reforms on its own. Fourth, if Republicans can attract Democrats to make additional fixes, great. If not, Republicans think they’ll be covered.

“I would be a lot more concerned if it wasn’t because of how confident I am of the things you can do administratively,” said Rep. Mario Diaz-Balart (R-FL). “The replacement to me is very key. I feel very comfortable that you can do a great deal of it through the administration.”

Some Republicans are blindly confident their leadership has it covered, and is charting a path that the full spectrum of the GOP caucus — from its hard-right wing to its moderate center — can support.

“It’s being held fairly tightly, but that’s what they’re doing. They’re navigating that piece, right?” Rep. David Brat (R-VA), a member of the conservative House Freedom Caucus, told TPM. “And so, we have a lot of folks at home who are nervous abut that replace: Are we going to be covered? Is everybody still going to be covered? And then the pre-existing conditions and etc., and I think, from what I guess from what I heard so far, is that everybody is going to be pleasantly surprised, including myself.”

Health care experts and Democrats on Capitol Hill are dubious of the GOP “replacement” strategy though, arguing it will fall short of lowering premiums or deductibles – or covering the same number of people who received insurance under Obamacare.

“Republicans can unwind the ACA, but they cannot put anything in its place without Democratic votes, and so far Democrats have said they won’t be willing to play along,” said Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation. “In some ways, Republican strategy so far includes burning the bridge behind them with no clear path out.”

It’s not that Republicans have totally given up on crafting replacement plans. If anything in recent weeks there have been a slew of new ideas. The problem is that the rush of ideas gives the impression that maybe behind closed doors there is no secret plan and the reality remains that there is still no broad consensus around any one of the plans that have been proposed publicly.

Sens. Bill Cassidy (R-LA) and Susan Collins (R-ME) rolled out an Obamacare alternative in January. Members of their party quickly rebuffed it. Sen. Rand Paul (R-KY) rolled out his own Obamacare replacement plan at the end of January. There aren’t any co-sponsors. On Tuesday, Rep. Mark Sanford (R-SC) announced he would unveil his own replacement.

There are a myriad of issues where the GOP seems stuck. Republicans have yet to agree as a conference on what to do with states that have expanded Medicaid under Obamacare. Republicans from states that have expanded the social safety net want assurances that no one in their states will lose insurance under a GOP replacement plan. But not all Republican replacements make that promise. Republicans haven’t agreed on whether they should keep Obamacare taxes to fund their own replacement or whether to finance payments to insurers that incentivize providers to cover low income people.

A successful Republican replacement bill will have to attract moderates and Freedom Caucus members, senators from Medicaid expansion states and lawmakers from states that did not expand Medicaid. Experts, aren’t sure it can be done.

“It will come down to the question of ‘Is there a compromise that can work across these different interests?’ and I don’t know the answer to that,” said Judith Solomon, the vice president for health policy at the Center for Budget and Policy Priorities.

From the outside, Democrats are dubious Republicans can figure it out.

“I don’t see a path for them toward a replacement. I don’t think they can repeal without a replacement, and I don’t think they can come up with a replacement,” said Sen. Sheldon Whitehouse (D-RI). “I think they’re like the band in ‘Animal House’ that walked into the dead-end ally.”

Senate Minority Whip Dick Durbin (D-IL) said he’s “skeptical.”

“Unless they have a secret plan they’ve been devising over six years, I have no evidence that they have any suitable replacement plan,” Durbin said.

In the House, Republicans have started holding hearings on narrow bills that would soften regulations on insurers. Those bills – because they are regulatory reforms – could not be put into a reconciliation package. But, the limited nature of those proposals, like loosening the age bands (rules that dictate how much more you can charge the elder vs. the young) reveal the small scope of the GOP’s replacement aspirations.

Republicans are still going to try to sell what ever slight changes they make, as a “replacement,” of course.

But calling it an Obamacare replacement, doesn’t necessarily make it so.

“I could see a much clearer path if what Republicans had promised in the campaign had been tweaks to the ACA. One can easily imagine that path,” Levitt said. “The path to completely repealing and replacing? It is still hard to see how they get there.”