Even after losing the White House, GOP leaders would have leverage because the exchange markets are experiencing major problems (See "Angst over ACA insurance exchanges may translate to changes"). Democratic presidential nominee Clinton, who has promised to expand coverage and improve affordability under the law, will need to make those markets financially viable for insurers by increasing enrollment of younger and healthier Americans.
Both Republican and Democratic observers say compromise remains a long shot. The GOP would have to set aside its repeal-or-bust stance on the ACA. Clinton would have to risk alienating her party's left wing, which backed single-payer insurance coverage during the primaries.
Still, “the chances of a deal are higher than they've been,” said Gail Wilensky, a veteran health economist who was Medicare administrator under President George H.W. Bush.
“It might be easier (to cut a deal) if Clinton is president,” said John Goodman, a conservative health policy strategist. “The problem is the Democrats can't be seen to be repealing Obamacare, and the Republicans can't be seen making Obamacare work better.”
Even if Republicans lose the Senate, a President Clinton would face continued opposition in the House, which is likely to stay under GOP control. But she would have administrative leeway to give states Section 1332 waivers. “There may be some areas where Clinton could make some progress, but it would be tweaks here and there,” said Lawrence Jacobs, a liberal-leaning expert on healthcare politics at the University of Minnesota.
Allowing red states to tinker with Medicaid—forcing low-income residents to make small contributions, for instance—will run into strong resistance from the left.
Wilensky said Clinton could score points with Republicans by relaxing the Obama administration's guidance on the 1332 waivers that restricts states' ability to integrate their exchange and Medicaid markets. That would enable lower-income people to maintain plan and provider continuity as their income fluctuates.