(Story updated at 3:41 p.m. ET)
The path to repealing the biggest health reform legislation in a generation suddenly became very clear early Wednesday, the day after Donald Trump won a stunning victory and the Republican party retained control of Congress.
With Republican control of the White House, Senate and House of Representatives, President-elect Trump's threats to repeal the Affordable Care Act are now quite real. Despite the GOP control, however, health policy experts have said taking health insurance coverage away from those who just received it will be difficult.
House Speaker Paul Ryan said Wednesday he expected to “hit the ground running” after the inauguration and finally fix the ACA, which he described as “collapsing under its own weight.”
Ryan, who was a reluctant Trump supporter, credited the GOP sweep to the president-elect and noted that Trump is asking Congress to repeal the ACA.
Senate Majority Leader Mitch McConnell also told reporters that repealing the ACA was high on the GOP agenda. "I would be shocked if we didn't move forward and keep our commitment to the American people," he said.
President Barack Obama's signature healthcare reform law—with its success in pushing the U.S. uninsured rate to a record low, requiring individual health insurance coverage and expanding Medicaid in all but 19 states—is now all up in the air. Analysts have estimated that repeal would add $353 billion to the federal deficit and that as many as 20 million people would lose coverage.
The GOP has vowed to “repeal and replace” the ACA since it was first approved six years ago. But the more than 70 votes needed meant little to Obama and his veto pen in the White House. That all changes with a Trump administration.
Trump clamped onto the party line on healthcare early in his candidacy and has called the ACA a “catastrophe.” He has been less clear, however, on what he would put in place of the ACA, citing vague conservative stalwart ideas such as creating high-risk pools, allowing insurance to be sold across state lines and expanding health savings accounts.
There is little evidence any of these efforts would show success in improving quality or reducing healthcare costs.
The GOP could attempt to repeal the ACA in budget reconciliation talks that will begin next week. They would need only 51 votes in the Senate, which they have, to make some big changes that would essentially gut the act. There is already a blueprint in legislation that Obama vetoed last year.
They could stop funding for: the subsidies that have helped people in the exchange plans afford their premiums; the payments toward insurers that allow for lower cost-sharing on silver plans; federal assistance to states that expand Medicaid; and penalties for people who do not buy insurance.
This would essentially mean the end of the exchanges, Medicaid expansion and the individual mandate. All that would survive are requirements that insurers not discriminate against people with pre-existing conditions and the ability for children to stay on their parents' insurance plans until age 26. Trump and other Republicans have praised these provisions and their popularity with the general public mean they aren't likely to go away.
Regarding the cost-sharing reduction payments to insurers, the new administration is almost certain to stop defending a lawsuit brought by House Republicans that contended the Obama administration was illegally making the payments through an appropriation meant for tax refunds when Congress refused to fund the payments regularly.
Dropping support for House v. Burwell is another death knell.
Still some analysts said full repeal and eliminating coverage for millions of people wouldn't be a cakewalk for the GOP.
Emily Evans, managing director of Hedgeye Risk Management, said in a newsletter that policy changes, particularly in healthcare, are typically slow.
“Shouts of repeal and replace notwithstanding, what happens next is not likely to be sudden or even complete in the minds of many ACA haters,” she said. “The fact is, wholesale repeal of laws—especially laws as far reaching as the ACA—is difficult.”
At a Brookings Institution event where the implications of the election were discussed, John Hudak, senior fellow of governance studies, said the many members of Congress who have promised to repeal the ACA now have no excuse not to go through with it.
Stuart Butler, senior fellow of economic studies, said he didn't think a full repeal would happen overnight, however. It would be more likely that some aspects are repealed but efforts to help people obtain coverage would continue, mostly at the state level.
The White House has some leeway in interpreting the law, Butler said. “I think you could see a dramatic change in the nature of the law without actually a change in the law,” he said.
Families USA Executive Director Ron Pollock vowed to vigorously fight any effort at repeal and hosted a call Wednesday afternoon with other organizations that support the law. Although the ACA has survived many efforts at repeal, the expanded GOP control creates a new problem, he said. “This constitutes by far the largest threat we've ever experienced,” Pollock said.
ACA advocates should try to find senators who could filibuster repeal efforts. The push to save the ACA needs to be immediate and strong, but there is a “meaningful chance to avoid significant damage,” he said.
Healthcare leaders, while not immediately vocal about the election results' impact on their business, likely will not welcome Trump's proposed changes. Modern Healthcare's second-quarter CEO Power Panel, a survey of 86 healthcare CEOs, found that the executives overwhelmingly backed the ACA and supported its goal of pushing providers away from fee-for-service medicine and toward delivering value-based care.
Ryan said he was excited to go into a lame-duck session knowing a Republican president would be entering the Oval Office in January.
“It's not just the healthcare law,” Ryan continued, alluding to the possibility of relaxing regulations on energy production and environmental laws, both issues of concern to public health experts, in an effort to jump-start jobs.
Shortly after Ryan's speech, Clinton publicly conceded the presidency to Trump and urged Americans to “keep doing our part to keep building that better, stronger, fairer America.”
With several million votes still to be counted Wednesday morning, Clinton held a narrow lead in the popular vote. Global stock markets and U.S. stock futures reacted poorly to Trump's victory but later recovered. The Dow Jones industrial average was up almost 1% in midday trading in New York. Stocks of hospital companies Tenet Healthcare Corp., HCA and Community Health Systems were trading lower, while insurers Aetna, Cigna Corp. and Humana were gaining.
Obama said he had invited Trump to a meeting at the White House Thursday to discuss the transition. Obama praised Clinton for being the first female presidential nominee of a major party.
Trump said during his victory speech early Wednesday that the nation owed Clinton "a major debt of gratitude" for her years of public service. But supporters at his victory party on Tuesday continued to chant “lock her up,” a persistent theme during his campaign.
A few national news network pundits as well as healthcare policy analysts suggested recent spikes in health insurance premiums in the ACA markets helped lead to Clinton's downfall. Although the increased costs affected few people overall, the headlines could have fueled anger at the ACA and Democrats in general.
Exit polls showed that 58% of voters thought the ACA should be repealed. About 15% said healthcare was a top issue for them.