Obamacare repeal rushed forward by GOP; realistically, what can we expect next?

House Republicans on Friday (January 13, 2017) took the first step in repealing President Obama’s signature healthcare law with a 227 to 198 vote on a budget resolution passed earlier in the week by the Senate, although some House Republicans voted against the measure because of concerns it puts in motion a process to repeal the Affordable Care Act without a simultaneous replacement.

House #Republicans took the first step in repealing #Obamacare Click To Tweet

The resolution includes instructions to repeal the ACA through the budget reconciliation process, according to Inside Health Policy. Republicans have said there will be two reconciliation tranches aimed at repealing and replacing the law.

Republican governors, Democrats and some industry stakeholders had urged lawmakers not to take steps to repeal the law without an immediate replacement. Kentucky Governor Matt Bevin (R) recently told Talking Points Memo that he advocates repealing and replacing the law simultaneously.

Massachusetts Governor Charles Baker (R) also raised concerns about the repeal strategy in a letter to House Majority Leader Kevin McCarthy (R-CA) on January 11, 2017.

“In addition to expanding healthcare coverage, there are other important provisions contained within the Affordable Care Act. These include but are not limited to patient protections such as the ban on pre-existing conditions exclusions, elimination of annual or lifetime limits and gender inequities.” He went on to say, “Any changes to the Affordable Care Act must also take into account the impact changes would have on the Medicaid program.”

As Congress ponders options related to health reform,

“We believe that a measured and objective analysis of the opportunities and challenges for states in the current federal landscape is essential. During this period of deliberation, it is important that coverage gains, patient protections and market stability are maintained,” Gov. Baker wrote.

Members of the House Freedom Caucus, including Justin Amash (R-MI), voted thumbs down on the budget resolution. Leading up to the vote, the Freedom Caucus said that between their caucus and moderate Republicans there might be enough members to block the vote, says Inside Health Policy.

“Some people allege that this budget is necessary to begin the repeal of Obamacare. That is false.” A House Liberty Caucus press release said, “‘Reconciliation instructions’ to begin that process can be included in any budget.”

But House Speaker Paul Ryan (R-WI) and President-elect Donald Trump are adamant a repeal and replacement of the law will happen simultaneously or concurrently.

The repeal bill’s provisions will need to take effect and be implemented and that won’t happen instantaneously, says The New York Times. Members of congressional leadership have said that they want a stable transition between the old healthcare system and the new one that they are hoping to develop. That means there will be delays to implementation built into their repeal bill. The exact period of delay is not clear, but it’s likely to be in the two-to-four-year range.

Lawmakers may not have control over what happens to insurance markets in the aftermath of the bill, but consumers are unlikely to see major changes to their health insurance this year because contracts are already signed and regulations are already in place for this plan year. Major disturbances could begin as soon as early next year.

Then, next year, big changes could begin. A lot depends on the details of the bill, whether Congress passes additional legislation, and what other actions the Trump administration takes to regulate insurance markets.

But people most likely to experience big changes are those who buy their own health insurance, whether in an Obamacare marketplace or directly from an insurance company. Many people with Medicaid coverage could lose their coverage or see substantial changes at the end of the delay period.

Steve’s Take:

Taking political partisanship and its ever increasing dominance out of the “repeal and replace” debate can seem like a hopeless impossibility these days. As with picking stocks, future winners and losers are impossible to predict. But trends—-predicated on facts, and I don’t mean the fake variety—-can be discerned with some effort and calm the rhetoric such that cooler heads and hearts prevail.

Let’s start with the GOP’s reconciliation approach to the “repeal” step in this massive undertaking to dismantle the Affordable Care Act.

Reconciliation can be used to accomplish several things. Republicans could employ it to change the individual mandate; reduce, rather than eliminate, subsidies; or phase out Medicaid expansion funds to apply salve to the wound. Federal commitments to paying insurance companies for taking on the additional risk of Obamacare enrollees could be altered although congressional members most certainly would be held accountable by their constituents.

If the Republicans decide against the nuclear option to reconciliation, any one of the above actions could nullify federal contracts with insurers and permit them to depart from the exchanges. This means that irrespective of the individual mandate, any such rules could destroy the public/private collaboration that’s been a hallmark of the exchanges so far and send millions of citizens back into the dreaded “uninsured” category.

Employing rose-colored lenses, Obamacare would be repealed and replaced simultaneously. That’s precisely what our President-elect and House Speaker Ryan are pledging. This notion however runs smack into the brick wall of reality and I, for one, believe all Republicans actually realize this.

Behind the scenes, they have taken up a plan to repeal portions of the ACA in the near term, and eventually replace it further down the road. Perhaps not the perfect tactic, but it enables political promises to be kept now while developing later the necessary components of a workable strategy based on solid data. This should minimize disruption and public blowback during the transition from Obamacare to Trumpcare.

It is this yin and yang nature of the political and practical that creates a seemingly hopeless situation on Capitol Hill. That’s why an immediate repeal and prolonged replacement plan is the best and only option. And Republicans understand this.

Now that the “repeal” step has been taken, experts from the left and the right must grapple with sensible, realistic mechanisms to enhance the regulatory schema. As pointed out by Forbes, it is well-accepted that insurance markets are unbalanced. It’s also evident that the unbalanced markets are creating losses for insurers and premium increases for consumers.

Although this isn’t the Republicans’ fault, it is their problem. Once the process of dismantling the ACA begins in earnest, Republicans will be tasked with making the improvements so earnestly promised during the 2016 campaigns but with details left to the imagination.

At the outset for example, one thing that reconciliation probably can’t be employed to accomplish his removal of the provisions of the ACA that prevent insurers from denying coverage for pre-existing conditions. The Atlantic points out that any modifications to that requirement would have to evolve from the “replace” side of “repeal and replace,” and be initiated within the ordinary filibuster-included rules. That constraint under reconciliation might be the Achilles’ heel for Republicans because the requirement for coverage of pre—existing conditions would require an individual mandate to be implemented.

Republicans undoubtedly recognize there is a problem with “repeal and replace,” and desperately want to address and fix it. They are currently in the process of grappling with ways to resolve the dilemma by their own reconciliation of how to stabilize the insurance market within the self-inflicted overhang of a “repeal and delay” strategy.

Bottom line:

The practical reality for healthcare industry stakeholders and consumers to grasp is Republicans are not politically suicidal enough to immediately terminate insurance coverage to 20 million people. They are not going to allow the insurance markets to disintegrate. But they need to get the hard work accomplished this year if they want to implement a major tax-reform reconciliation plan in early 2018. This is because only one reconciliation bill can be passed per year.

As we are reminded daily by the mass media, the increasing separation among Republicans about just what shape a replacement bill should take could drag out the entire process while each day more people are gaining health coverage. This only serves to mobilize more opposition from the left and potentially drag out the process even further.

Steve's Take: Will #GOP take a bipartisan approach to #Obamacare? We'll see Click To Tweet

The GOP has an enormous, daunting challenge ahead of it and the political pressures for a solution that satisfies all stakeholders and citizens will only increase in the weeks and months ahead. Perhaps in the process of crafting a solution, partisanship might be set aside in the interests of the people our representatives are supposed to serve. I refuse to believe I’m the only dreamer out here. Stay tuned and we’ll find out together.