Repeal-and-delay: a risky health care strategy

If you can’t repeal and replace the health care law all at once, what about just repealing it first, and coming up with new ideas later?

That was the preferred political strategy of many in Congress after the election, but it was ultimately rejected by the White House and House Speaker Paul Ryan, who determined Republicans should repeal and install a new plan simultaneously.

Now, as Republican senators balk at the health bill their leaders have drafted, several politicians have suggested it’s time to return to the original idea. Such a strategy would come with tremendous political risks for Republicans and practical risks for consumers, many of whom might end up dealing with zombielike markets.

President Donald Trump himself helped launch a boomlet of repeal-now-replace-later speculation last week, when he tweeted that a repeal-only bill would be better than nothing. Now a few conservative lawmakers have echoed that message. Sen. Ted Cruz, R-Texas, who is also pushing an amendment to the comprehensive bill, said Thursday a “clean” repeal bill would be an appropriate alternative.

The theory is that the repeal bill would come with a one- or two-year fuse, and that the looming explosion would compel lawmakers to compromise and pass something else in a hurry. The Congressional Budget Office provides a pretty good idea of what such an explosion would look like, if Republicans excised the parts of “Obamacare” they could repeal without provoking a filibuster by Democrats.

The partial repeal would cause 18 million people to lose insurance coverage in the first year, and 32 million fewer Americans would have health insurance in a decade. Over the course of that decade, the average insurance premium would double, the budget office said.

Partial repeal would lead to such messy consequences because it would undo only the funding for Obamacare, not its regulatory structure. The health law balances rules that require robust insurance benefits and that allow sick people to buy insurance at standard prices; there are financial incentives for low-income Americans to buy insurance, and penalties for many Americans who remain uninsured. Both the law’s carrot and its stick would go away under a repeal bill.

The budget office has not assessed what might happen during a one- or two-year delay period, because it hasn’t evaluated legislation that included it. But a range of experts said when the idea first came into fashion they were skeptical of the idea that the status quo could float along until a new political compromise arrived.

Obamacare’s insurance markets depend on the voluntary participation of private insurance companies, and most of them see those markets as difficult long-term investments. Many of them might choose to retreat to safer lines of business in the uncertain “zombie” period between the passage of such a repeal bill and its ultimate enactment.

The result might be chaos for consumers unable to find affordable plans — or even any plans, in some parts of the country. Lawmakers may not be able to control the timing of Obamacare’s demise with such a strategy.

The plan also assumes a looming crisis will provide enough political incentive for a future compromise. Trump has been clear he wants to do more than just get rid of chunks of Obamacare. His stated health care goals include providing a robust safety net for the poor, covering more Americans and driving down the cost of insurance.

Those goals are clearly in some conflict with the current Senate bill. But they are even more of a mismatch with the projected consequences of a bill that would simply defund Obamacare’s main coverage provisions.

There are also reasons to wonder if increased pressure would, in fact, bring lawmakers closer to compromise. The very Republicans most enthusiastic about a repeal-only strategy seem less interested in pursuing a separate, costly replacement provision.

Cruz has argued for years that Obamacare should be undone wholesale, and he has not been alone in that view. Democrats, who worked hard to expand coverage under the health care law, might wish to prevent sharp coverage losses. But they might also be willing to wait and let Republicans take the blame for any chaos they unleash.

That makes a repeal-and-delay strategy a gamble, not just practically, but politically, too.