Perhaps the biggest challenge Republicans face in assuming total control of the federal government is how to fulfill their promises to scrap Obamacare and prevent a massive health care crisis in which millions lose their coverage.
GOP leaders have been living in an unreal world, talking of repealing President Barack Obama’s signature law now but delaying replacement for several years. In the meantime, Vice President-elect Mike Pence says, the Trump administration can deal with any problems by executive action.
That’s why several Republican senators are trying to change the script by delaying repeal until a replacement can be devised. And they got some encouragement from President-elect Donald Trump, though he didn’t indicate how they could take both steps — and do it quickly.
Most Democrats realize suggestions of an easy fix are a myth, so they’re playing defense, blaming the GOP in advance for the potential worst case scenario. Senate Democratic Leader Chuck Schumer says the GOP mantra is “Make America Sick Again.”
Still, barring a compromise, a train wreck is likely. First, as generations of lawmakers can attest, health care is incredibly complicated. That Obama got Congress to enact the 2010 Affordable Care Act was nothing short of a legislative miracle.
Second, it may be impossible to scrap unpopular parts of the current law, such as the rapidly rising premiums, the mandate requiring universal participation or a penalty, the diminishing number of health care providers and the tax increases, and maintain such popular portions as insuring pre-existing conditions, providing coverage to age 26 and eliminating lifetime limits.
The biggest problem with the current GOP prescription, using a budget process that requires only a simple Senate majority, is that it would maintain services, while eliminating the taxes that pay for the costlier parts and the Medicaid expansion, while providing a big tax break to the wealthiest taxpayers.
Without that revenue, the whole structure might collapse, even if the legislation survives for several years, leaving millions without health care coverage.
One reason, Secretary of Health and Human Services Sylvia Burwell told the National Press Club, is that insurance companies might withdraw participation, jeopardizing coverage for up to 30 million Americans who get insurance from Obamacare and the expanded Medicaid.
“We haven’t seen a real proposal for replacement yet,” Burwell said, adding that any substitute needs to maintain the current law’s three main successes: retaining coverage for those who didn’t have it, protecting quality improvements in health care delivery and limiting future health care cost increases.
In a less partisan environment, both parties could cooperate to fix the current law’s problems. No Democrat thinks it’s perfect, and Senate Majority Leader Mitch McConnell noted on CBS’ Face the Nation that a President Hillary Clinton would have proposed changes.
But what he didn’t say is that Republicans would probably have opposed them and that, given current battle lines, prospects are minimal for any bipartisan fix.
The underlying political factor here is that, as unpopular as the law has been from the start, an increasing proportion of Americans prefer to fix it rather than replace it.
In fact, a recent Kaiser Family Foundation poll showed the proportion of Republicans favoring outright repeal has dropped to just over half of those polled. A quarter wanted it scaled back, rather than repealed, and one in 10 wanted it expanded.
And in the population as a whole, where polls have generally shown roughly half oppose the law, one-third of them wanted a bigger government role, not a smaller one.
Given these factors, it’s hardly surprising there are divisions among both House and Senate Republicans. Though GOP leaders have talked of taking two or three years to implement a replacement, more conservative House Republicans prefer to scrap it immediately.
But the real action is in the Senate, where the GOP has a mere 52-48 majority, and several Republicans have expressed doubt about the repeal and delay strategy, both conservatives like Sens. Rand Paul, R-Ky., and Tom Cotton, R-Ark., and moderates like Sens. Susan Collins, R-Maine, and Lamar Alexander, R-Tenn.
“It shouldn’t be finally repealed until we have a replacement ready,” said Alexander, a potentially key player as chairman of the Health, Education, Labor and Pensions Committee.
The stakes are enormous, both substantively and politically. As Burwell noted, 30 million Americans face a possible loss of health care. And just as Obama paid a political price for aspects of the initial law, Trump and the Republicans face a similar challenge.
Prompt repeal may satisfy the GOP’s ideological hard core. But the ultimate impact will depend on whether Trump and his party can find a way to maintain health care for the many Americans who have come to expect it.
• Carl P. Leubsdorf is the former Washington bureau chief of the Dallas Morning News.
