At the top of the GOP hit list are the medical device tax—projected to bring in $29 billion over 10 years to help fund the law's premium subsidies—and the employer mandate—projected to produce $130 billion in penalties against employers. Losing those revenues would put a big crimp in Obamacare funding.
“Permanently putting a spike through the heart of the employer mandate is the most obvious thing,” said Joe Antos, a healthcare policy expert at the conservative American Enterprise Institute. The employer mandate already has been delayed by a year, suggesting some queasiness in the Obama administration about its potential impact on jobs and the economy.
Bills to repeal those provisions are likely to garner some Democratic support, particularly the 2.3% sales tax on medical devices. Democrats who represent states and districts where medical device manufacturers are located, such as Sen. Al Franken (D-Minn.), have opposed the tax. Last year, a largely symbolic vote in the Senate to eliminate the tax garnered 79 votes, including support from 34 senators who caucus with the Democrats. A repeal measure in the House has 275 co-sponsors, including 46 Democrats. But there's no agreement on how to replace the tax's revenue, which gives Democrats pause.
“It's been pretty clear there's a bipartisan coalition in the House and Senate that believes the medical device tax has been very harmful to jobs,” said Rep. Erik Paulsen (R-Minn.), chief sponsor of the House proposal. “It was rolled into the healthcare bill simply to raise revenue without an understanding of what the repercussions would be.”
But some experts question the profitable device industry's claims that the tax is hurting companies, noting that the tax also applies to imported devices so there's no financial incentive for healthcare providers to switch to foreign suppliers. And the tax does not apply to exported products, so it does not affect U.S. manufacturers' sales to other countries. These critics note that the device industry's case against the tax is based largely on studies funded by the industry itself.
Another provision that's attracted some Democratic support is allowing so-called copper plans with lower actuarial value to be sold through the exchanges. The insurance industry has been pushing to permit copper plans designed to cover only half of medical costs to be sold through the exchanges. Sen. Mark Begich (D-Ala.), who faces a tough re-election contest, has introduced legislation that would allow such plans. The bill is co-sponsored by five Democrats and one independent. But some experts question how attractive these plans would be to consumers and whether they would leave lower-income people vulnerable to unaffordably high out-of-pocket costs.
Republicans also are likely to push ideas that long have circulated in conservative policy circles but gained little traction on Capitol Hill given the partisan stalemate and opposition from powerful interest groups. That includes allowing the sale of health plans across state lines, restricting medical malpractice lawsuits and increasing the use of tax-free health-savings accounts. All of these ideas were part of an ACA-repeal-and-replace package put forth this year by Republican Sens. Richard Burr of North Carolina, Tom Coburn of Oklahoma and Orrin Hatch of Utah. State insurance commissioners long have opposed allowing sales of health plans across state lines, arguing that they would lose the ability to protect consumers against insurance abuses.
Most of these proposed changes in the ACA would cost the government serious money. That means Republicans either would have to find a way to offset these revenue losses or accept an increase in the federal budget deficit. That's frequently been a source of conflict in the GOP-controlled House in recent years, with any effort to raise revenue certain to rile up hard-line conservatives.
“Virtually anything you can think of that might be sensible does bang up against CBO scoring,” Antos said.
There's also the question of whether Obama would sign any legislation that dents his healthcare law. If he caves on one provision, the argument goes, it could embolden Republican Obamacare opponents to seek further changes and significantly roll back the law.
“I think ultimately the president will be open to some changes,” said Yevgeniy Feyman, a fellow at the Manhattan Institute who studies healthcare issues. “But I don't think radical changes are realistic while there's no veto-proof majority or while Obama's still in office.”