The phrase “repeal and replace” the Affordable Care Act long has been popular among Republicans. But the “replace” part has always been thorny. With Republicans taking control of the White House and having majorities in the Senate and House, the prospect of leaving up to 30 million people without healthcare appears to have chilled the rhetoric.
Still, members of the newest Congress took swift action Tuesday to make good on their longtime promise of repealing the ACA. But more Republicans are suggesting a slow death of the landmark legislation and a gradual replacement. That opens the door to keeping key provisions of the ACA, such as subsidies to help people buy insurance and the provision allowing people to stay on their parents' plans until they're 26.
"What's going to happen is once there is recognition of what the consequences are going to be of simply repealing this legislation, you'll see a lot more modification than outright repeal and replace,” said Stuart Butler, a senior fellow at the Brookings Institution. “It will be called repeal and replace, but ... it's going to look a lot more like what we have."
Hours after members of the 115th Congress were sworn in Tuesday, Sen. Mike Enzi (R-Wyo.) introduced a budget resolution instructing committees to repeal parts of the ACA that have budget and tax implications. Debate on the resolution is expected to begin Wednesday.
Senate Republicans need over 51 votes to approve the resolution, instead of the 60 votes needed to avoid a Democratic filibuster. There are now 52 Republicans in the 100-member chamber.
The House Energy and Commerce and Ways and Means committees and the Senate Finance and Health, Education, Labor and Pensions committees have until Jan. 27 to specify which parts of the ACA would be repealed and how long to delay implementation of the repeal in order to craft a replacement package.
Republicans leaders have floated the idea of waiting to institute a replacement, perhaps as long as three years. There are also varying ideas on how long people with insurance under the ACA would be able to retain coverage during a transition period after repeal.
"We're talking about a three-year transition now that we actually have a president who's likely to sign the repeal into the law," Senate Majority Whip John Cornyn (R-Texas) told reporters recently. "People are being understandably cautious to make sure nobody's dropped through the cracks."
It's unclear exactly how much of the law could be repealed through budget reconciliation. Congress last year passed a budget reconciliation bill that would have repealed the ACA's tax hikes, subsidies and Medicaid expansion. President Barack Obama quickly vetoed the bill.
This time, Congress may try to eliminate the much-maligned individual mandate to obtain health coverage by removing the penalty for not doing so. This key part of the law was meant to push more young and healthy people to get insurance so that insurers could continue to afford coverage of the older and sicker.
However, removing the individual mandate would “in many ways, be the worst of all worlds,” Butler said. “You have all the requirements in place but you don't have the funding to support it.”
Joe Antos, a health policy expert at the right-leaning American Enterprise Institute, said a key aspect of the ACA that will likely remain is subsidies to buy coverage, although they will almost certainly be structured differently. Many conservative plans tie subsidies to age, but this doesn't address income differences.
“That's an issue that's going to have to be resolved somehow.”
Federal support for state Medicaid expansion may also stay, at least for a while since several states with Republican governors expanded because they would receive matching federal funds. They could be slowly phased out and states could experiment with more ideas for funding expansion, Antos said.
“I think that's going to be the theme,” he said. “Let's let the state's decide because they know their local market better.”
Virtually all Republican plans retain the popular provision first instituted by the ACA that allows people under the age of 26 to remain on their parents' insurance plans and President-elect Donald Trump voiced his approval of the clause after meeting with Obama.
Most ACA replacement ideas don't protect those with pre-existing conditions. They would ban discrimination so long as the person maintains continuous coverage. Currently, the ACA bans any insurer from denying coverage to someone with chronic conditions.
Obama and Vice President-elect Mike Pence are scheduled to meet with leaders of their respective parties Wednesday to review very different game plans for moving forward.
Tuesday morning, Trump tweeted that ACA repeal should be a top priority for the new Congress because plans created under Obama's signature healthcare law offer “lousy healthcare.”
Trump has not explicitly endorsed any specific proposal or policy.
Antos said this lack of a coalescing force means more "hurry up and wait" for legislators.
“This is a policy that's going to take a little bit longer than one might expect because they're going to need some sign from the White House, and it's not clear when those policy directions might come,” he said.
Meanwhile, hospital and insurance leaders say they need more specific ideas to help them plan and advocate.
In a statement Tuesday, the executive president of the American Medical Association called on lawmakers not to decrease the number of people with coverage.
“We believe that before any action is taken through reconciliation or other means that would potentially alter coverage, policymakers should lay out for the American people, in reasonable detail, what will replace current policies,” Dr. James Madara said. “Patients and other stakeholders should be able to clearly compare current policy to new proposals so they can make informed decisions about whether it represents a step forward in the ongoing process of health reform.”
Enzi, in a news release posted on his website, said the resolution providers consumers with that choice.
"Today, we take the first steps to repair the nation's broken health care system, removing Washington from the equation and putting control back where it belongs: with patients, their families, and their doctors," he said.
Jennifer McLaughlin, senior associate director of governmental affairs for the Medical Group Management Association, said that medical group practices are in a holding pattern as they await congressional action.
“It really will come down to what the specifics are, and we're not really seeing any consensus,” she said.