You could almost hear healthcare industry stakeholders sigh with relief when Democrat Doug Jones was projected the winner of the special Senate election in Alabama Tuesday night.
That's because Jones' narrow victory over Republican Roy Moore dims GOP hopes of successfully reviving their drive to repeal and replace the Affordable Care Act and cutting and block-granting Medicaid in 2018. Providers, insurers, and consumer advocacy groups almost universally opposed the GOP effort, fearing massive insurance coverage losses and healthcare spending cuts.
The former federal prosecutor's win in Alabama Tuesday reduces the Republican margin in the Senate, with the chamber to be split 51-49. That gives just two GOP senators the power to block another effort by Senate Majority Leader Mitch McConnell to pass a repeal-and-replace bill through the budget reconciliation process requiring just 50 votes. Now Maine's Susan Collins and Alaska's Lisa Murkowski can stymie such a bill on their own, whether or not Arizona's John McCain, who's battling brain cancer, remains in the Senate to join them again in voting no. Collins and Murkowski balked over large proposed cuts in Medicaid and the impact on people with pre-existing medical conditions in the last repeal bill.
"When you didn't have the votes before and you just lost one, that doesn't suggest increased opportunity," said Tom Miller, a conservative health policy analyst at the American Enterprise Institute who favors replacing the ACA.
President Donald Trump and some congressional GOP leaders have said they want to return to the repeal-and-replace effort after passing their tax cut legislation. Cutting spending on the ACA's premium subsidies and Medicaid expansion would help them offset the estimated $1.5 trillion increase in the federal budget deficit resulting from the tax bill.
"The administration is confident Congress will come back to town in the new year and work to repeal and replace the Obamacare disaster," White House deputy press secretary Hogan Gidley told the Washington Post.
"I don't think we're ever going to be able to get away from" healthcare, Sen. John Cornyn of Texas said last week.
Of course, that was before Tuesday's election, when Trump and his fellow Republicans expected Moore to win, maintaining their 52-48 margin in the Senate. Jones' upset victory changes the calculus.
"You'll hear more noises about reviving repeal-and-replace, but their best shot has come and gone," Miller said.
What's more likely now is the Trump administration will focus on rolling back the ACA through administrative actions. Those include giving states more leeway to impose conditions on Medicaid eligibility that reduce enrollment, such as work requirements and cost-sharing.
The administration also is about to release new federal rules allowing cheaper, leaner health plans that don't meet ACA requirements on minimum essential benefits, guaranteed issue and community rating.
Meanwhile, as part of their tax cut bill, Republicans are rushing toward repealing the ACA's requirement that nearly everyone buy health insurance. If they pass that provision, which insurers and providers dread, they can claim a big political victory in knocking down one of the pillars of the healthcare law.
That might take pressure off Republicans to pass a broader ACA repeal. "The rollback of the individual mandate (would be) a major achievement for them," said Chip Kahn, CEO of the Federation of American Hospitals.
Kahn hopes Republicans pause in pushing other major changes in the law while insurers and providers see how repealing the mandate affects the market. The Congressional Budget Office estimated that ending the mandate would lead to 13 million fewer people with insurance by 2027 and additional premium increases averaging 10% a year. "Our preference is to let things settle down," he said. "Let's see how we can all adjust to that big change."
Given Tuesday's GOP election loss and current public opinion running against Trump and his party, Republicans are unlikely to score any more big legislative wins on healthcare in 2018, Miller said.
"They're not going to pull off a miracle of passing something that's already not popular," he said. "They'll have to sink or swim with what the tax bill delivers them."
