Repub­li­cans scram­ble to ease con­cerns about what re­places Oba­macare


Af­ter years of promis­ing to re­peal the Af­ford­able Care Act, a grow­ing num­ber of Repub­li­cans are balk­ing at the prospect of do­ing so quickly with­out a firm plan to re­place it.

As the Se­nate be­gins vot­ing Wed­nes­day on a path to elim­i­nate the land­mark health-care bill, some Repub­li­cans are wor­ried about the po­lit­i­cal fall­out and un­cer­tainty of start­ing to roll back Oba­macare with­out know­ing how the process will end.

Pres­i­dent-elect Don­ald J. Trump was among the Repub­li­cans ex­press­ing con­cern Tues­day.

“I feel that re­peal and re­place have to be to­gether, for very sim­ply, I think that the Democrats should want to fix Oba­macare,” Trump said in an in­ter­view with The New York Times. “They can­not live with it, and they have to go to­gether.”

Se­nate Ma­jor­ity Leader Mitch McCon­nell (R-Ky.) and House Speaker Paul Ryan (R-Wis.) in­sisted Tues­day that they have no in­ten­tion of mov­ing ahead with re­peal with­out a con­sen­sus re­place­ment plan. But some Repub­li­cans re­mained con­cerned about tak­ing a sin­gle vote — on a bud­get mea­sure that sets cer­tain ground rules for what is to fol­low — be­fore they get

through what is likely to be an ex­tremely dif­fi­cult process of pro­duc­ing an al­ter­na­tive.

The chaos fo­cused at­ten­tion on the po­lit­i­cal peril Repub­li­cans face in seek­ing to de­liver one of their top po­lit­i­cal prom­ises. Re­peal­ing the 2010 health-care law would be cer­tain to have pow­er­ful rip­ple ef­fects for both pa­tients — 20 mil­lion of whom have gained cov­er­age through var­i­ous ACA mech­a­nisms -- and the health-care sys­tem as a whole.

The speed with which lead­ers had hoped to act be­came part of the prob­lem on Tues­day as Repub­li­can lead­ers con­sid­ered ex­tend­ing a Jan­uary 27 dead­line for com­plet­ing a re­peal bill. Con­ver­sa­tions with Repub­li­can sen­a­tors and a re­view of their state­ments show that nearly a dozen have pub­licly ex­pressed some level of con­cern about re­peal­ing the law with­out a re­place­ment.

“There are a lot of peo­ple that have con­cerns about do­ing a re­peal with no re­place­ment or at least some guid­ance on re­place­ment,” said Sen. Bob Corker (R-Tenn.) who has co-spon­sored lan­guage to de­lay the non­bind­ing dead­line for re­peal leg­is­la­tion un­til March 3.

“The train leav­ing the sta­tion this week is not a big event, it’s when the train pulls back into the sta­tion that’s the big event,” Corker ex­plained.

Sen. Lisa Murkowski (R-Alaska) said that while there is a lot of dis­sat­is­fac­tion on health care among Alaskans, “They at least know what they are deal­ing with right now.”

She added: “The thought that we would take away what they are see­ing now, whether it’s the ben­e­fits they are get­ting from Med­i­caid ex­pan­sion, the sub­si­dies they are get­ting on the in­di­vid­ual mar­ket ... there is a lot of anx­i­ety and a lot of un­cer­tainty and they are ba­si­cally ask­ing me: ‘What comes next? We want to know.’”

Such con­cerns did not ap­pear to jeop­ar­dize the fren­zied set of pro­ce­dural votes slated to be­gin Wed­nes­day known as a “vote-a-rama.” Those votes are an at­tempt to tin­ker with a bud­get mea­sure to es­tab­lish a process for re­peal­ing the health-care law — first by re­fer­ring it to the rel­e­vant com­mit­tees and cul­mi­nat­ing in floor votes on ac­tual re­peal leg­is­la­tion, prob­a­bly this spring.

McCon­nell ar­gued Tues­day that Trump’s com­ments on re­peal-and-re­place are “not in any way in­con­sis­tent with what we’re all aim­ing for.” But the time­line be­ing pur­sued by con­gres­sional Repub­li­cans does not square with Trump’s de­mand in his in­ter­view to vote on re­peal as early as next week, high­light­ing the dis­con­nect be­tween the pres­i­dent-elect and GOP con­gres­sional lead­er­ship.

“It is dif­fi­cult for us to sit here and have a se­ri­ous con­ver­sa­tion about re­peal­ing and re­plac­ing next week,” Sen. Tim Scott (R-S.C.) said Tues­day.

In ad­di­tion, Trump’s firm com­mit­ment to quick re­place­ment leg­is­la­tion is at odds with some Repub­li­cans seek­ing a more grad­ual process.

“This is go­ing to be a joint ef­fort of the ad­min­is­tra­tion, the House and the Se­nate to put to­gether the re­place­ment. And ob­vi­ously, we’re go­ing to be talk­ing to [Trump] about how to do that and the peo­ple that’s he putting in place that we’re go­ing to con­firm will be key play­ers,” said McCon­nell of Trump.

“In my view we need to cast most of our votes on [re­place] be­fore sum­mer­time,” said Sen. La­mar Alexan­der (R-Tenn.), chair of the Health, Ed­u­ca­tion and La­bor Com­mit­tee that will par­tic­i­pate in the process. “That will prob­a­bly take two or three steps and then take two or three years to im­ple­ment it over time.”

McCon­nell did not of­fer specifics about the tim­ing of re­peal-and-re­place votes while Ryan in­sisted that full re­peal would not hap­pen un­til Repub­li­cans had ral­lied be­hind a re­place­ment plan.

“We are go­ing to use ev­ery tool at our disposal, through leg­is­la­tion, through reg­u­la­tion to bring re­place con­cur­rent with re­peal,” Ryan told re­porters.

Ryan tried to re­as­sure skit­tish rank-and-file Repub­li­cans Tues­day dur­ing a weekly closed-door ses­sion by vow­ing to move swiftly so that some re­place­ment el­e­ments can move in tan­dem with a re­peal mea­sure in the com­ing months.

The Obama ad­min­is­tra­tion, mean­while, con­tin­ued its ef­forts to demon­strate that the in­surance cre­ated un­der the ACA is pop­u­lar, de­spite what of­fi­cials eu­phemisti­cally term “head­winds” caused by the law’s un­cer­tain fu­ture. Fed­eral health of­fi­cials on Tues­day re- leased up­dated en­roll­ment fig­ures, which show that, by Christ­mas Eve, 11.5 mil­lion peo­ple had cho­sen health plans for 2017 through Health­ and sim­i­lar mar­ket­places run by a dozen states.

That is nearly 300,000 more than dur­ing the equiv­a­lent time a year ago, the of­fi­cials said. How­ever, the num­ber of peo­ple sign­ing up for the first time, about 2 mil­lion, is 1 mil­lion fewer than last year.

It re­mains un­clear ex­actly which por­tions of the law Repub­li­cans will seek to dis­man­tle through the bud­get process. But re­peal leg­is­la­tion Repub­li­cans pushed through Congress slightly more than a year ago might of­fer a guide.

Un­der that bill, ve­toed by Pres­i­dent Obama, most Amer­i­cans no longer would be re­quired to carry health in­surance or pay a fine, and sub­si­dies would have ended that cur­rently help more than 80 per­cent of about 10 mil­lion peo­ple have bought health plans through ACA’s mar­ket­places.

The pre­vi­ous re­peal leg­is­la­tion also would have elim­i­nated an ex­pan­sion of Med­i­caid that 31 states have adopted.

All these changes would, in turn, have an im­pact on in­sur­ers, hos­pi­tals, and the phar­ma­ceu­ti­cal in­dus­try.

While there is broad GOP con­sen­sus about do­ing away with the law, Repub­li­cans do not agree on the shape or tim­ing of a sub­sti­tute.

“I think peo­ple are con­cerned about is hav­ing the flex­i­bil­ deal with things like how do we keep the melt­down on Oba­macare from oc­cur­ring while we’re try­ing to make the longer-term re­place­ment,” said Se­nate Ma­jor­ity Whip John Cornyn (R-Texas), the sec­ond-rank­ing Repub­li­can.

Cornyn, McCon­nell and Ryan all in­sisted they are con­fi­dent they can craft a re­place­ment that sat­is­fies the ma­jor­ity of their party. But they are likely to need the votes of at least eight Democrats to re­place the ACA.

Repub­li­can lead­ers are re­ly­ing on spe­cial bud­get pro­ce­dures to re­peal por­tions of the health-care law with­out the threat of a block­ade by Se­nate Democrats. Se­nate rules al­low bud­get leg­is­la­tion to be ap­proved with 51 votes rather than the nor­mal 60 needed to pass nearly ev­ery­thing else. There are 52 Repub­li­cans in the Se­nate, en­sur­ing that a uni­fied GOP can act on re­peal with­out Democrats.

But any new health-care leg­is­la­tion would be sub­ject to nor­mal Se­nate rules and Democrats warn they are not go­ing to res­cue Repub­li­cans on re­place­ment.

That is ex­actly what some Se­nate Repub­li­cans are try­ing to avoid.

“I want to be sure peo­ple who are depend­ing on their sub­si­dies or Med­i­caid ex­pan­sion are held harm­less in this tran­si­tion,” said Sen. Rob Port­man (R-Ohio), who is co-spon­sor­ing the amend­ment de­lay­ing the dead­line for writ­ing a re­peal bill.


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