For the past six years, no law has served as a larger GOP whipping post than the Affordable Care Act, and the Republican sweep Tuesday of political Washington has imperiled the ACA’s expansive reach, putting at risk the insurance that more than 20 million Americans have gained.
During the final week of his campaign, President-elect Donald Trump vowed to repeal the 2010 health-care law so quickly that he might summon Congress into a special session to accomplish the task. “We will do it, and we will do it very, very quickly. It is a catastrophe,” he said.
Yet shortly after dawn Wednesday, a top Republican Senate spokesman said the chamber had not yet formulated its strategy for the coming session. In recent years, the GOP-led House has voted more than five dozen times to rescind the ACA, and Speaker Paul D. Ryan (R-Wis.) returned to that point late Wednesday morning when he described the law as “collapsing under its own weight.”
While President Obama has blocked congressional attempts to repeal the statute, “now we have President Trump coming, who is asking us to do this,” Ryan said.
The ACA’s most ardent supporters immediately began a counteroffensive to foment opposition to reversing ways the law has upgraded coverage and provided the first federal subsidies for some middle-class Americans to help them afford health plans.
Families USA, a liberal consumer-health lobby, was organizing a midafternoon call with hundreds of ACA advocates from about 40 states to begin mapping a grass-roots campaign.
“The clock is ticking, because Republicans appear to be saying health care is going to be the first item on their list with repeal of the ACA being the banner for that, so we realize this work has got to be done quickly and effectively,” said Ron Pollack,
Families USA’s executive director for three decades. “This will be the most intense fight I remember,” he said. “One should never underestimate an extraordinary backlash that occurs when people have something that they really value and it is taken away.”
The new Senate’s Republican majority will remain short of the 60 votes needed for a full repeal. But Congress demonstrated in the past year that it could use the upper chamber’s reconciliation process — requiring just 50 votes — to send a bill undoing major ACA elements to the White House. Last winter, President Obama vetoed that legislation.
“But President Trump would sign,” said Tevi Troy, an ACA critic who is a former deputy health secretary and chief executive of the American Health Policy Institute. “Congress intentionally set it up so they could demonstrate a legislative pathway” to reverse large portions of the law. “It was a strategic move.”
Larry Levitt, senior vice president at the Kaiser Family Foundation, was bluntly pessimistic. “The ACA as we know it would seem to be toast,” he said Wednesday morning. “Repealing Obamacare has been such a mantra for conservatives. . . . The difficulty for them comes now in trying to come to some consensus about how to unwind it and what to replace it with.
“I don’t think there has been a reversal of any public benefit that would be as large as this,” Levitt continued. The only other significant reversal by Congress of a major health care policy — the expansion of Medicare to include catastrophic coverage — took place in 1989 before the benefit took effect.
For his part, Trump has said that he favors keeping one key aspect, which has outlawed the old practice by many insurers of refusing to cover people with preexisting medical problems or charging them more than other customers. But the insurance industry has long said it would have a hard time abiding by this rule unless virtually all Americans are required to have insurance — a central part of the ACA that Trump wants to abolish.
A day after the election, it is impossible to know the precise timing and mechanism for Republicans’ plans to carry out their years-long goal of killing Obama’s signature domestic policy achievement. The law has brought about the most sweeping changes to the health-care system in a half-century.
Still, congressional budget analysts and outside health policy experts have estimated the likely impact of replacing the ACA with a series of broad-brush health policies that Trump sketched out in his campaign.
The Congressional Budget Office forecast that, over the coming decade, repealing the law would cause the deficit to grow by $353 billion, while the number of people with insurance would drop by about 24 million. Rand Corp. has predicted that in 2018, the first full year of Trump’s tenure, his campaign’s health plan would add nearly $6 billion to the deficit, primarily by undoing a slowdown in Medicare payments under the law. It also would decrease the number of insured by about 20 million people, according to Rand.
Pollack said the law’s elimination would reach far beyond the loss of insurance for people who have gained it through the ACA marketplaces or the expansion of Medicaid in 38 states. Without the law, he said, insurers could return to a practice of charging women more for coverage, and consumers would no longer be guaranteed limits on their out-of-pocket expenses.
In the short term, the sudden doubt about the law’s future also has the potential to confuse — and perhaps thwart — the fourth open-enrollment season for ACA health plans through HealthCare.gov and similar state-run insurance marketplaces. The three-month sign-up period began eight days ago amid spiking insurance rates and diminished insurance options in many parts of the country.
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