Before the holiday break, Republicans were committed to repealing Obamacare. And they wanted it done as fast as they could.
But even as the Senate began to move forward with dismantling the health care system, Republicans returned from the holidays with a sinking recognition that executing an immediate repeal of the Affordable Care Act could trigger a major backlash.
In December, the Urban Institute released a detailed warning of how the insurance market could collapse if Republicans charged ahead with plans to partially repeal the Affordable Care Act through reconciliation — a process that avoids a Democratic filibuster but is limited in its scope — without a clear replacement. Even Republican and libertarian health care experts were explicit in closed-door meetings with Republicans that the GOP was taking a huge gamble by repealing Obamacare without a replacement. As it turns out, some of the people who benefited the most from Obamacare are the same ones who voted for Trump and the Republicans. The Washington Post cited a fascinating number: Among poor whites, the uninsured rate has dropped from 25 percent to 15 percent. If Republicans were to pull back that safety net, there appears to be a growing recognition that they would bear the consequences.
The mood of Capitol Hill Republicans now is cautious. When asked about the timeline for repeal, House Ways and Means Chairman Kevin Brady (R-TX) told TPM that it was “to be determined,” and would likely come in several steps. There is a new emphasis on doing no harm. Members are urging leadership to be transparent with the American people, and internal disagreements over when to repeal the law, how far to go and what to replace it with are bubbling to the surface.
“Please have hearings in the committees of jurisdiction, and I know that people are in a hurry so if you have to have hearings five days a week and into the night, and on the weekends, then have the hearings,” said Rep. Mark Amodei (R-NV). “The legislative branch is supposed to be the transparent one.”
What once was a campaign slogan now must be done, but jamming the bill through could come with unintended consequences rank-and-file Republicans are waking up to.
Here are five major tension points that have emerged as Republicans debate their Obamacare repeal plan.
Just a reminder, we aren’t even to the hard part yet: how to replace Obamacare.
Should repeal come before a replacement?
GOP leaders made clear soon after the election their intent to repeal Obamacare right away even if that meant a replacement would not come until later. The idea was to include a transition phase to give them time to cobble together a replacement. But as the risks of this strategy have become more apparent, some rank-and-file Republicans have privately grown uneasy with it.
“They are talking about replacing it at some point, but they are operating under the illusion that somehow that we’ll be able to put pressure on the Senate Democrats to come to some kind of a replacement because there are going to be issues in their states that need to be addressed,” a House Republican, who asked for anonymity to speak candidly, told TPM last week. “I’m not yet persuaded.”
So far, it appears leadership is putting fingers in their ears to their concerns, but a revolt in the Senate, where the margin is slim to pass repeal, is growing. Four senators — Sens. Susan Collins (R-ME), Rand Paul (R-KY), Tom Cotton (R-AR) and Bob Corker (R– have publicly stated their discomfort with repealing without a replacement, putting the majority vote needed to pass repeal in danger.
Sen. Rand Paul (R-KY) says he won’t support any repeal legislation without seeing a replacement to go with it.
“[It] would be best for our country to go ahead and replace it with something that works and repeal at the same time,” Corker told reporters Friday, according to a report from the Hill.
Should repeal help pay for a replacement?
The Obamacare repeal bill passed by Congress and vetoed last year by President Obama immediately repealed taxes that have helped pay for the program. If the new repeal effort eliminates those revenue sources immediately, paying for the replacement plan become politically very difficult.
Some Republicans have acknowledged that a replacing Obamacare will be costly, and the political hurdles to re-raising taxes after the ACA’s revenue boosters are dismantled is high.
“There are a lot of conversations going on about whether to hold on to some of that to fund appropriate replacements or not, and what the right timing frame is to set for that replacement to be in place,” Sen. Roy Blunt (R-MO) said on Capitol Hill Thursday.
Among the options being considered is delaying Obamacare taxes for the phase-out period, rather than repealing them entirely, so they’ll be available to fund an ACA alternative. Additionally, the Senate bill that will act as a vehicle for repeal lays the groundwork for a reserve fund to capture the money that would be saved by dismantling some aspects of Obamacare.
But even before lawmakers begin discussing the cost of a replacement, how they save for it has become a point of contention. Rep. Mark Meadows (R-NC), chairman of the House Freedom Caucus, which has a penchant for derailing Republican legislation, has suggested that the reserve provisions are a deal-breaker for him (the caucus itself won’t decide its official stance until Monday evening).
Brady, the House Ways and Means chairman, said leadership hadn’t taken a position yet either.
“It hasn’t been decided,” he said.
Chairman of the House Ways and Means Committee Kevin Brady (R-TX) will help lead House Republicans on the repeal process.
Another complicating factor is that Sen. Paul has cited the Senate bill’s failure to balance the budget as reason he can’t support it. He met with the House Freedom Caucus on Thursday morning but it was unclear how much of a sticking point that would be.
“People are disturbed by the fact that as conservatives they would be voting for a budget that adds $9.7 trillion to the debt and never balances. So I think there is some concern among conservatives about it,” Paul told TPM.
Should insurers be “bailed out” to stabilize the post-repeal marketplace?
GOP lawmakers are promising a stable transition, but facing an irony that the sort of provisions that would incentivize insurers to stay in the individual market while a replacement is put together are similar to ACA measures they railed against in the Obama era.
Some Republicans are admitting that they’ll have to temporarily put their disgust with so-called “insurer bailouts” on hold to smooth the dismantling of Obamacare, while others worry that may make them look like hypocrites or are even expressing a frustration that they would need to help insurers at all.
“We can’t just let people go without health care. It’s just that simple,” Sen. Orrin Hatch (R-UT) said last month. “On the other hand, there’s a lot of unrealistic expectations in this thing, too.”
Should repeal defund Planned Parenthood?
House Speaker Paul Ryan (R-WI) last week reiterated his chamber’s intention to defund Planned Parenthood in their Obamacare repeal bill, as was the case in the 2015 “test run” ACA repeal that was vetoed by President Obama. Other Republicans have been less-than-committed to that plan, with HELP Committee Chair Lamar Alexander telling reporters when asked about Ryan’s comments last week, “let’s see,” and “we’re still writing” the legislation.
Though Senate Republicans were able to muster up the votes to pass the defund Planned Parenthood provision when it was part of the 2015 repeal bill, it’s proven to be a thorny issue for some GOP lawmakers. Collins has opposed the measure, and Sen. Lisa Murkowski (R-AK), who supported the 2015 bill, voted against defunding Planned Parenthood in other legislation.
Should Medicaid expansion be repealed?
Another growing concern for Republicans is what the party will do to help states that have expanded Medicaid using funding from the Affordable Care Act. Republicans were always skeptical of the Medicaid expansion, but more than half a dozen GOP governors eventually expanded the program and senators from red states want to protect their constituents who are benefiting from it.
The 2015 House repeal bill did away with the federal funding for Medicaid expansion after two years. And in interviews with TPM, it is clear that Republicans from states like West Virginia and Ohio –where Medicaid expansion had drastically lowered the uninsured rate– have an interest in protecting it.
Sen. Shelley Moore Capito (D-WV) is one of the Republicans who has expressed concern about preserving Medicaid expansion in her state.
But in 2015– when the the terms of the test repeal bill were being drafted, Republican Sens. Marco Rubio (R-FL), MIke Lee (R-UT) and Ted Cruz (R-TX) fought to make sure that repealing Medicaid was included, and have more recently stated they wouldn’t accept anything less than what 2015 bill dismantled.