President-elect Donald Trump and congressional Republican leaders are promising to make repeal and replacement of the Affordable Care Act one of their highest priorities in the first 100 days after they take full control of the federal government in January.
But both Republican and Democratic health policy experts say the road will be rocky and that it may take a lot longer and involve a lot more compromises than they think. They predict Republicans may seek Democratic support in crafting a replacement to avoid full responsibility for any problems that follow.
Some predict bipartisan support is highly unlikely if Republicans pursue their goal of completely wiping out the ACA framework rather than making more modest fixes. Odds for cooperation are even more remote if Trump and congressional leaders also seek to restructure Medicare, which he and House Speaker Paul Ryan signaled last week. “I cannot imagine the Dems going along,” said Theda Skocpol, an expert on healthcare politics at Harvard University. “They would be out of their minds.”
Trump said Thursday his top three agenda items would be border security, the economy and healthcare reform. “Very important, we're looking very strongly at healthcare and we're looking at jobs,” he said.
His shocking election victory over Democrat Hillary Clinton completely scrambles the widespread thinking in the healthcare industry that the ACA framework for the healthcare system is here to stay. Now leaders in all healthcare sectors have to reassess their strategies and decide whether to accommodate the big changes proposed by Trump and congressional Republicans or try to fight them. Already, hospital leaders in Texas and elsewhere are urging Republicans to find ways to preserve the law's coverage gains.
Nevertheless, Trump, Ryan, and Senate Majority Leader Mitch McConnell are expected to pursue repeal of the ACA's individual mandate, premium subsidies, Medicaid expansion, and various taxes including the “Cadillac plan” and medical-device taxes, possibly with a two-year delay to allow time for developing a replacement package. That's in line with the GOP repeal bill passed last January and vetoed by President Barack Obama.
Last week, Trump and Ryan expanded the healthcare agenda to include “modernizing” Medicare, widely seen as an allusion to Ryan's plan to convert Medicare into a defined contribution, “premium support” program that could impose higher costs on seniors. Ryan told Fox News that “Medicare has got some serious problems because of Obamacare. Those things are part of our plan to replace Obamacare.” During the election campaign, Trump repeatedly said he wouldn't touch Medicare.
The Republicans have indicated they will try to enact the ACA changes through an expedited budget reconciliation process, which only requires 51 votes in the Senate for passage but can be used solely to address provisions affecting taxes and revenue. They would have to pass separate legislation through the regular legislative process to address other ACA features such as the exchanges, minimum essential benefits, guaranteed issue of insurance and the CMS Innovation Center.