WASHINGTON — Republicans are already laying the groundwork for a rapid repeal of President Obama’s signature health-care law beginning on the first day of the new Congress, before President-elect Donald Trump is even sworn in.
But the urgent efforts to make good on a Republican campaign promise six years in the making obscure major party divisions over what exactly to replace Obamacare with and how to go about it, and how long a transition period to allow before the law’s insurance would go away.
Hard-liners are pushing to move as fast as possible, bolstered by a Republican base eager to see lawmakers follow through on years of promises. But key congressional leaders are keenly concerned about potentially throwing millions off their insurance plans and repeating what they have long decried as Democratic missteps eight years ago, sparking a fierce political backlash by moving too far, too fast.
While Trump could sign legislation gutting the Affordable Care Act before the spring bloom, a full replacement could take months, if not years.
“I’d like to do it tomorrow, but reality is another matter sometimes,” said Sen. Orrin Hatch, R-Utah, chairman of the Senate Finance Committee that will help lead the “repeal and replace” efforts. “We have to live with the real world. And the real world right now is that the Democrats won’t help with anything.”
Hatch and other high-ranking Republican senators are pushing for an extended transition period that could keep large portions of Obamacare in effect until 2019 or beyond, allowing time to carefully craft a replacement and push the final debate past the midterm elections.
Many of them, like Sen. Susan Collins, R-Maine, have been chastened by conversations with insurers and state regulators who are warning of chaos in the market for individual insurance if Congress moves rashly.
“I don’t want to leave the 84,000 people in Maine who are buying insurance on the exchange uninsured because, all of a sudden, two-thirds of them who have subsidies have lost that subsidy,” Collins said.
But those Republicans are clashing with party colleagues –many of them sent to Congress in the midterm, anti-Obama waves of 2010 and 2014 – who see little reason to dawdle.
“The history of this place is, the longer it takes, the more exponentially the probability grows that it’ll never get done,” said Rep. Mark Meadows, R-N.C., the new chairman of the hard-right House Freedom Caucus. “Republicans have been saying they have a replacement plan for over two years, so why do we need three years?”
Part of the problem is that Republicans have never been able to agree on a replacement plan, despite railing against Obamacare for nearly eight years now. Their foot-dragging is a function of internal divisions and the political peril of floating a detailed alternative that would be closely evaluated for costs and benefits. Trump has also been vague, promising a “terrific” replacement that will provide “great health care at a fraction of the cost.”
The current battle centers on when exactly to schedule Obamacare’s sunset. But other fights loom – over what precisely a replacement plan should look like, whether Obamacare’s Medicaid expansion will continue, whether lawmakers should also now tackle the future of Medicare, and how Congress should assist insurers during the transition.
The battle lines, however, are familiar, with “establishment” Republicans on one side and conservative insurgents, mainly in the House, on the other. Those dynamics last year helped force House Speaker John Boehner, R-Ohio, to retire.
Come Jan. 20, Obama will no longer serve as a foil for Republicans, and while Senate Democrats could block parts of a health-care overhaul, the real fight will occur inside the Republican Party.
Senate Majority Leader Mitch McConnell, R-Ky., has announced plans to put an Obamacare repeal on the Senate floor come Jan. 3. But that will only set the stage for a future repeal bill that will have to tackle major decisions such as a sunset date and interim measures to stabilize insurance markets.
So far, Trump and key Republicans have shied away from taking firm positions on repeal and replace, but they have done little to tamp down the expectations of conservatives expecting a swift, wholesale substitute.
“We’re going to repeal Obamacare lock, stock and barrel,” Vice President-elect Mike Pence told the Heritage Foundation recently. “The number one priority of this administration is to keep that promise to the American people.”
Hard-liners see Pence and Rep. Tom Price, R-Ga., Trump’s pick for health and human services secretary, as allies in their push for quick and decisive action. Pence called on Congress to pass a repeal bill “with all deliberate speed” but pledged only to then “set into motion a process to replace it.”
House Speaker Paul Ryan, R-Wis., said Thursday that Republicans would move “as well and as fast as we can but make sure that the transition does not pull the rug out from under people.”
Conservative activists who pushed a take-no-prisoners approach toward the Obama administration say their patienceis limited.
“When Republicans have the House, the Senate and the White House, you don’t wait,” said Adam Brandon, president and chief executive of FreedomWorks, a conservative advocacy group. “I’m a Cleveland Indians fan. I only get a shot at a World Series every couple decades. When you have a shot to do it, you do it. That’s it.”
Democrats and many health-care experts warn that a swift repeal could lead insurers to stop selling policies to individuals on federally mandated exchanges. More than 12 million Americans are covered under those policies.
Health and Human Services Secretary Sylvia Mathews Burwell briefed behind closed doors Senate Democrats on Thursday on the expected unraveling of Obamacare’s insurance exchanges.
“Delayed replacement is a situation where it is basically repeal and chaos in terms of what will ensue, because of the uncertainty that will get presented to insurers, providers, consumers and states,” Burwell said after the meeting.
Republicans want to end Obamacare’s system of penalties and subsidies. But many – including Trump – want to continue to ban insurers from denying coverage or sharply increasing rates for the sick.
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