Political observers across the spectrum have long expected Obamacare to be high on Congress’ list of changes it wants made, but the speed of repeal efforts has taken most of them by surprise.
As a candidate, President-elect Donald Trump repeatedly said he would install a better health-insurance system than the Affordable Care Act, one that would improve access and lower costs.
“On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare,” he wrote on his campaign website. “However, it is not enough to simply repeal this terrible legislation. We will work with Congress to make sure we have a series of reforms ready for implementation that follow free market principles and that will restore economic freedom and certainty to everyone in this country. By following free market principles and working together to create sound public policy that will broaden healthcare access, make healthcare more affordable and improve the quality of the care available to all Americans.”
The first part of that statement—repeal of the Affordable Care Act—isn’t even waiting for the first day of his administration.
House Republicans are already at work scuttling the law, which has provided health insurance for 20 million Americans who previously were without it. Among the most important provisions of the law for people with diabetes and other chronic health issues, the law prohibits health insurers from denying coverage because of pre-existing conditions and ended the lifetime caps on coverage. It also subsidizes the cost of health-care premiums for people of modest means.
In the opening days of the new year, Rep. Mike Enzi (R-Wyoming) introduced a budget resolution calling for repeal of the parts of Obamacare that involve budget and taxation. The resolution is a way of getting around an expected Democratic filibuster in the Senate of any attempts to undo the law. The resolution calls for legislation to come to the Budget Committee by Jan. 27, just a week after Trump takes office.
“Today, we take the first steps to repair the nation’s broken health care system,” Enzi said in a press release, “removing Washington from the equation and putting control back where it belongs: with patients, their families, and their doctors.”
Despite the limited nature of the resolution, critics of Enzi’s proposal say, it would in effect gut the health-coverage law by eliminating the individual mandate, which requires Americans to carry health insurance or face tax consequences. Without the mandate, insurance pools would collapse and insurers would withdraw from the system, leaving millions of Americans without coverage. And many congressional Republicans who favored repealing the law right away had said they wanted to delay writing a replacement for months or even years. For many of them, that means voting now but holding off on actually implementing the repeal until a comprehensive new bill can be drawn up.
But Trump has indicated that he won’t go along with the latter idea. He wants movement on both fronts, and fast. According to a report Tuesday (Jan 10) in the New York Times, the president-elect is demanding that Congress repeal Obamacare immediately and replace it almost as soon.
“His remarks put Republicans in the nearly impossible position of having only weeks to replace a health law that took nearly two years to pass,” the Times reported.
And during his press conference on Wednesday, Trump said a replacement for the Affordable Care Act would happen “essentially simultaneously” with its repeal.
“It will be repeal and replace,” he said. “It will be essentially simultaneously. It will be various segments, you understand, but will most likely be on the same day or the same week, but probably the same day. Could be the same hour.”
Experts in the economics of health care have raised doubts about whether that’s possible. Days after the election, Harvard University economist David Cutler pointed out in a Washington Post column that rewriting the law along the lines that Trump has suggested carries real pitfalls.
For example, Cutler wrote, replacing health insurance subsidies with a tax deduction for healthcare premiums would leave low-income people unable to afford coverage. Because they already pay a lower tax rate, the deduction would be of far less value to them than to wealthy or middle-class Americans.
“Independent estimates suggest repeal would cause about 20 million people to lose coverage” he wrote, “only one-quarter of who would purchase insurance with the deduction. The rest wouldn’t be able to afford it.”
Trump also called for increasing competition among insurers by allowing them to sell across state lines.
“But experience is not on Trump’s side,” Cutler noted. “Three states have already eliminated restrictions on out-of-state sales of insurance—Georgia, Maine and Wyoming—and not a single insurer has entered any of these markets.”
At this point, the one thing that seems certain about the future of the Affordable Care Act is sharp division and quickly changing priorities among Republicans about how to end it. And today the U.S. Senate voted to instruct key committees to draft repeal legislation by January 27. The bill will now go to the House of Representatives for a vote expected to take place on Friday.
“They [Republicans] want to kill ACA but they have no idea how they are going to bring forth a substitute proposal,” declared Senator Bernie Sanders of Vermont.