Since 2010, the Affordable Care Act (ACA), aka Obamacare, has been the health care law of the land. And since the ACA became the law of the land, Congressional Republicans have tried to repeal at least portions of it dozens of times.
Now, with the GOP holding majorities in both the House and the Senate and with their presidential candidate slated for the White House, we can expect their next attempt to be successful.
How’s that gonna work?
There are different ways Republicans can do away with key provisions of the ACA. The most likely way they will go about it is by introducing a sneaky little thing called a reconciliation bill. For any old piece of legislation, the minority party in the Senate actually holds quite a bit of power to prevent it from becoming law, so long as they have more than 40 members in the 100-member chamber.
That’s because they can filibuster – meaning, any Democratic senator could take the floor of the Senate and just refuse to stop talking. The Senate’s ordinary rules make endless debate possible, meaning a vote can’t be called. Unless, that is, there are at least 60 senators who vote to end debate. Republicans only have a slight majority, so that probably wouldn’t be attainable.
But there’s a type of bill that can be introduced with rules to prevent a filibuster, and that’s a reconciliation bill. The rules for reconciliation legislation limit the amount of time the bill can be debated. Only bills related to taxes, government spending and federal debt can be introduced as reconciliation bills.
The Senate and House actually passed legislation to repeal key components of the ACA earlier this year; they got it through the Senate by using the reconciliation maneuver. Of course, President Obama vetoed it. And, as Politico reported, Senate Budget Chair Mike Enzi spoke in favor of undoing Obamacare this way in 2017. We can expect this to hit the floors of Congress shortly after Donald Trump moves into Obama’s old digs in January, almost certainly cutting funding for the biggest components of the ACA.
What’s it mean?
The burning question, especially for the 20 million Americans who got health insurance through Obamacare, is: What the hell is going to happen to us? That depends on so many variables. Let’s look at what passed Congress earlier this year, and what the GOP and Trump have been saying about all this, for an idea of what might go down.
The 2016 repeal legislation would have undone Obamacare by removing government from the health care market, cutting federal subsidies to insurance companies that enable most people on Obamacare to purchase plans at discounted rates and doing away with the “individual mandate,” the provision that places a financial penalty on individuals who don’t buy insurance.
About 85 percent of people on Obamacare get subsidies to pay for their insurance, so repealing that provision would serve as a primary wrecking ball to the legislation. Also, getting rid of the individual mandate means less money coming into the system to pay for things like the elimination of insurance denial for people with pre-existing conditions.
Trump said he’d like to maintain the provision of Obamacare that prevents insurance companies from denying coverage on the basis of pre-existing conditions, as does the GOP “Better Way” plan, but it’s unclear how their coverage could be funded without money coming in from a broader base of insured people.
Another key provision that the bill rolled back – and not without some in-fighting among the GOP – is the Medicaid expansion enacted by the ACA voluntarily by governors in 31 states, including vice president-elect Mike Pence in Indiana. This made insurance through Medicaid available to hundreds of thousands of people across the country.
The GOP Better Way plan calls for undoing the Medicaid expansion and replacing it with a pre-determined grant or allotment to states aimed at reducing federal funding and increasing states’ efforts to lower health care costs. It also suggests implementing work requirements for people to qualify for Medicaid, meaning they’d need to prove they are employed, seeking employment or undergoing training in order to do so.
When and what next?
In addition to the questions of what exactly GOP repeal legislation would do away with are the crucial questions of when and with what they would replace it. Presumably, Republicans in Congress along with the president-elect have an incentive to include a transition phase out of Obamacare, during which they implement their preferred methods of expanding access to insurance (which will rely more on free market principles, like competition between insurance companies, than on federal funding of subsidies).
The 2016 repeal legislation included a two-year phase-out plan so states and the federal government could figure out how to keep people insured. Based on the Better Way plan and what Trump called for during his campaign, that might look like allowing people to put money into health savings accounts that wouldn’t be taxed, monthly tax credits people could use to offset costs of insurance and measures to increase competition between insurance companies and health care providers, like making their prices publicly available.
Obamacare’s likely on its way out through reconciliation legislation that stands a good chance of passing in Congress and garnering Trump’s signature. That bill will probably gut Obamacare by ending the subsidies the government pays to offset lower-income people’s costs, repealing the individual mandate and ending Medicaid expansion as defined by the law.
But the repeal almost certainly won’t get into effect immediately, and the GOP will have a strong political incentive to replace it with something Americans can afford before people start losing their coverage under the ACA.
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Header image: Getty