This much is clear: No one knows what’s happening on ACA repeal
When it comes to repealing and replacing the Affordable Care Act, Democrats are from Venus, while Republicans are spread out between Mars, Saturn and Pluto.
Members of the two parties held dueling media events last week portraying the healthcare law from the perspective of entirely different planets, with the Democrats arguing it’s saved countless lives, and the Republicans calling it a “disaster” for the American people.
There’s so much confusion and anxiety about the GOP strategy— or lack thereof—for ACA repeal and replacement that well-connected Washington lobbyists and policy experts are asking news reporters, “What are you hearing?”
At a Heritage Foundation event, conservative House Republicans said they would start presenting their ideas for dismantling the law through an expedited budget reconciliation bill that could pass on a straight party-line vote. They argued for pushing ahead on rapid repeal without waiting for a full replacement package. They also favor abolishing all the taxes that pay for the ACA’s coverage expansions, a position at odds with more moderate Republicans worried about how to pay for replacement coverage.
House Speaker Paul Ryan (R-Wis.) says he’s sticking to his timetable to pass the repeal bill before the Easter recess in early April. The House leadership’s and President Donald Trump administration’s reported strategy is to include in the reconciliation bill significant replacement features, such as premium tax credits that are more modest than the ACA’s; state high-risk pools for people with pre-existing conditions; expanded health savings accounts; and Medicaid changes, perhaps including turning Medicaid into a program of capped federal payments to the states.
It remains uncertain whether such substantial policy changes would be ruled germane to a budget bill by the Senate parliamentarian.
Among Republican senators, though, the pace and tone sounded sharply different. Tennessee Sen. Lamar Alexander, chairman of the HELP Committee, said he’s waiting for the Trump administration to issue a replacement plan before his panel starts crafting legislation. Fellow Tennessee Sen. Bob Corker told reporters, “To be honest, there’s not any real discussion taking place right now.”
Democrats were preparing for full resistance. House Democratic leaders held a pro-ACA event in the Capitol, introducing a number of parents and children from around the country who have benefited from the ACA’s coverage expansions and protection from insurance discrimination based on pre-existing medical conditions.
House Democratic leader Nancy Pelosi of California and other top House Democrats at the event vowed they would only work with Republi- cans on changing the law if those changes expand and improve its coverage and patient protections.
Congress would be deadlocked if Senate Democrats take the same position—and so far they have. Republicans will need at least eight Democratic votes in the Senate to pass an ACA replacement package.
One unexpected development last week was the statement by North Carolina Rep. Mark Meadows, chairman of the hard-right House Freedom Caucus, that he would be open to two major requests from insurers to help stabilize the individual insurance market during a shortterm transition: funding the ACA’s costsharing reductions that insurers are required to offer lower-income enrollees, and restoring risk payments to insurers that sign up a disproportionate share of sicker members.
House Democratic leader Nancy Pelosi of California and other top House Democrats have vowed they would only work with Republicans on changing the law if those changes expand and improve its coverage and patient protections.
Providers are watching whether a GOP repeal bill will include a rollback of the ACA’s Medicaid expansion and a conversion of Medicaid to state block grants or per-capita grants, which almost certainly would mean a big cut in federal Medicaid funding and a spike in uncompensated care.
Maryland Rep. Steny Hoyer, the second-ranking House Democrat, said if the Republicans try to pass Medicaid restructuring through a budget reconciliation bill, there’s not much Democrats could do to stop it. But they will face powerful resistance, he predicted, from Republican governors in states that have expanded Medicaid.
James Capretta, a prominent conservative health policy expert, doubted that congressional Republicans could quickly push through a hugely controversial restructuring of Medicaid without taking more time to craft a political compromise with the states and other powerful stakeholders. “But the truth is no one really knows what the process will look like,” Capretta said. “It’s a difficult place they’re in, but that doesn’t mean they can’t do it.”