Republicans weigh electoral calculus on reviving ACA repeal push

As unlikely as it seems that congressional GOP leaders will try once again to repeal and replace the Affordable Care Act, both Republican and Democratic political observers say there's a small chance they refuse to rule it out.

Why? Conservatives remain furious that last year's Obamacare repeal effort failed. And with midterm elections looming, the GOP needs to fire up right-wing voters to help maintain control of Congress.

Sen. Lindsey Graham (R-S.C.) said he hopes to revive a new version of the repeal bill he co-sponsored with Sen. Bill Cassidy (R-La.) that narrowly failed in the Senate last fall. It's being developed by the Heritage Foundation and the Galen Institute, working with former Pennsylvania Sen. Rick Santorum.

"I haven't given up," Graham told the Hill newspaper on Wednesday.

It would reportedly convert ACA premium subsidies and Medicaid expansion dollars into block grant payments to the states, a model that is strongly opposed by hospital, insurance and consumer groups. Graham's office said it would share details of the plan "if and when we have something."

That has ACA supporters lighting warning beacons.

"There were so many people who said it was impossible last year, and it came down to one vote," said Chris Jennings, a Democratic healthcare strategist who advised the Obama administration and the Hillary Clinton presidential campaign. "You have to take it seriously or you are committing malpractice as advocates."

A GOP lobbyist who didn't want to be named said Republicans are split on whether to move forward with a repeal bill before the elections. Santorum and his allies argue that soaring premiums in the ACA markets give Republicans political cover to pass a major conservative reform bill. But Senate leaders, along with HHS leadership, don't want to deal with the issue now, and a White House aide pooh-poohed the effort Thursday.

Christopher Condeluci, a Republican healthcare lobbyist and former Senate staffer said congressional GOP leaders are torn between wanting to mobilize base voters by killing the hated Obamacare law and fearing a backlash against vulnerable Republican candidates in states like Arizona and Nevada where hundreds of thousands of people have gained coverage.

"This is a net political loser for Republicans, but I don't think they're listening to me," Jennings said.

Beyond that, some Republicans realize the Trump administration is already achieving their anti-ACA goals through administrative moves such as expanding short-term plans and association health plans that don't comply with the ACA. "Republican leadership can tell the mavericks, 'Let's not risk another legislative failure. We're doing it backdoor through our administrative actions,' " Jennings added.

A major hurdle to passing a repeal bill is that Congress would have to approve a new budget resolution, according to budget experts. That resolution would allow Senate Republicans to pass the bill through an expedited budget reconciliation process requiring only 50 votes, the only way they could evade a certain Democratic filibuster.

But passing a budget resolution would be very difficult given the limited congressional calendar and the upcoming elections, observers say.

Hospital and insurance groups do not welcome another GOP repeal drive, after spending last year lobbying hard against the various repeal bills' cuts in insurance coverage and Medicaid funding.

"We need actions at the federal level that increase the number of people covered," said Ken Janda, CEO of Community Health Choice, a not-for-profit health plan in Houston serving the Medicaid and ACA markets. "Instead, more than a year of legislative and regulatory blows to our healthcare system have resulted in higher costs and fewer people covered."

The Hospital and Healthsystem Association of Pennsylvania, where 1.1 million people gained coverage under the ACA, said it wants a plan that ensures that Obamacare's coverage gains and consumer protections are not jeopardized. "Reviving these failed (repeal) efforts only stands to create more uncertainty and instability, said Rachel Moore, an association spokeswoman.

Matt Fiedler, a fellow at the Brookings Institution's Center for Health Policy who served in the Obama administration, said the chances of passing a repeal bill before the election are "small though not zero."

"But if Republicans hold the House and gain a seat or two in the Senate, I would not be at all surprised to see Congress take up legislation after the election resembling the current package. So whatever is unveiled in this round is worth taking seriously insofar as it sets the scene for the future."