For Trump and GOP, ‘Oba­macare’ re­peal is com­plex and risky

Jamaica Gleaner - - HEALTH -

HERE’S THE idea: Swiftly pass a re­peal of Pres­i­dent Barack Obama’s health-care law, per­haps soon enough for Don­ald Trump to sign it the day he takes the pres­i­den­tial oath. Then ap­prove leg­is­la­tion re­struc­tur­ing the na­tion’s huge and con­vo­luted health-care sys­tem, de­spite Repub­li­can di­vi­sions, Demo­cratic op­po­si­tion, and mil­lions of jit­tery con­stituents. What could go wrong? With Repub­li­cans con­trol­ling the White House and Congress in Jan­uary, they’re faced with de­liv­er­ing on their long-time prom­ise to re­peal and re­place ‘Oba­macare’. Here are hur­dles they will face:

SPEED VS DELIBERATION

Trump and con­gres­sional Repub­li­cans will be un­der in­tense pres­sure from their core con­ser­va­tive sup­port­ers to re­peal Obama’s 2010 health-care law – and fast. Af­ter all, Congress al­ready sent Obama a re­peal bill last Jan­uary, which he ve­toed, and many GOP vot­ers will see no rea­son for de­lays this time.

But there prob­a­bly won’t be any­thing fast about Congress’ ef­fort to re­place Obama’s law, which is likely to take many months.

While the re­place­ment ef­fort is un­der way, Repub­li­cans will risk ag­gra­vat­ing up to 30 mil­lion peo­ple who are cov­ered by the law or buy poli­cies with prices af­fected by its in­sur­ance mar­ket­place. Democrats will be sure to ac­cuse the GOP of threat­en­ing the health care of mil­lions.

A SO­LU­TION

Noth­ing has been de­cided, but here is one likely sce­nario.

The new Congress, which con­venes Jan­uary 3, tries to quickly ap­prove leg­is­la­tion re­peal­ing Obama’s health-care law, maybe com­plet­ing it by Trump’s Jan­uary 20 in­au­gu­ra­tion or soon af­ter. But the re­peal would not take ef­fect un­til the fu­ture, per­haps a year later, to give law­mak­ers time to fash­ion a re­place­ment. The ver­sion Obama ve­toed had a two-year de­lay.

Seem­ingly ac­knowl­edg­ing that two-step process, Vice-Pres­i­den­t­elect Mike Pence said Sun­day on Fox News Sun­day that Trump “wants to fo­cus out of the gate on re­peal­ing Oba­macare and be­gin­ning the process of re­plac­ing Oba­macare”.

Be­cause Repub­li­cans will con­trol the Se­nate by just 52-48, Congress will first have to ap­prove special bud­get pro­ce­dures to pre­vent Democrats from stop­ping re­peal leg­is­la­tion by fil­i­buster. Bill-killing fil­i­busters re­quire 60 votes to end.

But those special rules would ap­ply only to items that af­fect the fed­eral bud­get. Repub­li­cans, for ex­am­ple, would need a sim­ple Se­nate ma­jor­ity to end IRS penal­ties against peo­ple who don’t buy in­sur­ance but would still need 60 votes – re­quir­ing Demo­cratic sup­port – for other changes such as rais­ing lim­its on older peo­ple’s pre­mi­ums.

House Bud­get Com­mit­tee Chair­man Tom Price (R – Ga) said that will re­strain Repub­li­cans’ abil­ity to ram a “lock, stock and bar­rel” re­peal through Congress.

GOP RISKS

One GOP dan­ger: Congress and Trump might re­peal Obama’s law, but while they’re labour­ing on a re­place­ment, ner­vous in­sur­ance com­pa­nies be­gin pulling out of mar­kets and rais­ing pre­mi­ums. In­sur­ers have been do­ing that un­der Obama, but now it would oc­cur un­der a Repub­li­can govern­ment.

An­other hazard: Congress’ work could spill into the 2018 cam­paign sea­son, when the en­tire House and a third of the Se­nate face re-elec­tion. Repub­li­cans will grow in­creas­ingly timid about any­thing that might anger vot­ers.

“We want to be the res­cue party in­stead of the party that pushes mil­lions of Amer­i­cans who are hang­ing by the edge of their fin­ger­nails over the cliff,” says Sen­a­tor La­mar Alexan­der (RTenn) who chairs the Se­nate Health Com­mit­tee.

GOP PATH­WAYS

Vir­tu­ally all Repub­li­cans want to get rid of the health law’s man­dates that in­di­vid­u­als buy cov­er­age or risk IRS fines, and that large em­ploy­ers in­sure work­ers.

They also want to erase taxes on higher-earn­ing peo­ple and the health-care sec­tor. And they’d like to re­tain parts of the law guar­an­tee­ing cov­er­age for peo­ple with pre-ex­ist­ing med­i­cal prob­lems and keep­ing chil­dren un­der age 26 on fam­ily plans.

Uni­fy­ing Repub­li­cans much be­yond that is a work in progress.

Trump’s health-care views have var­ied and lack de­tail. His cam­paign web­site touts tax de­duc­tions for health in­sur­ance pre­mi­ums and per­mit­ting poli­cies to be sold across state lines. He’d also re­vamp Med­i­caid, which sub­sidises health cov­er­age for low-in­come peo­ple, di­rect­ing fixed amounts of money to states and let­ting them struc­ture ben­e­fits.

House Speaker Paul Ryan (RWis) last sum­mer un­veiled an out­line of the House GOP’s so­lu­tion, though it lacked cost es­ti­mates and de­tails. It would pro­vide tax cred­its, im­pose taxes on the most gen­er­ous em­ploy­er­pro­vided health-care plans, re­vamp Med­i­caid and let Medi­care ben­e­fi­cia­ries pick private plans in­stead of to­day’s fee-for-ser­vice cov­er­age.

Se­nate Fi­nance Com­mit­tee Chair­man Or­rin Hatch (R – Utah) has also ad­vanced a frame­work re­ly­ing heav­ily on tax cred­its.

RE­MAIN­ING QUES­TIONS

Thirty-one states – in­clud­ing Pence’s In­di­ana, where he is gover­nor – plus the Dis­trict of Columbia have ex­panded Med­i­caid cov­er­age to nine mil­lion ad­di­tional peo­ple un­der Obama’s law. Cur­tail­ing that pro­gramme will di­vide Repub­li­cans.

Tax­ing the value of some em­ployer-pro­vided health plans, aimed at curb­ing the growth of costs, is “a po­lit­i­cal land­mine,” said GOP econ­o­mist Dou­glas Holtz-Eakin. Repub­li­cans have long re­sisted tax in­creases.

Obama’s law man­dates cov­er­age for in­di­vid­u­als be­cause with­out that re­quire­ment, many healthy peo­ple would forgo poli­cies, driv­ing up costs for ev­ery­one else and desta­bil­is­ing in­sur­ance mar­kets. Ryan has pro­posed shield­ing peo­ple from higher pre­mi­ums if they’ve had “con­tin­u­ous cov­er­age,” al­low­ing higher rates for peo­ple who have not had poli­cies, but Repub­li­cans have yet to de­cide how to keep in­sur­ance mar­kets vi­able.

United States Pres­i­dent Barack Obama

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