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The repeal of the Affordable Care Act has been a solid part of the Republican platform since Congress passed the bill seven years ago. Many current representatives and senators made the repeal Obamacare movement a key talking point on the campaign trail last fall.

With a solid Republican majority in the House, a slim-but-viable majority in the Senate, and President Donald Trump in office, many thought Obamacare’s days were numbered.

They may well be. But, for Americans and pundits alike, there are two key questions. First, what is taking so long? And, more importantly, what’s going to replace the Affordable Care Act? Perhaps the more complicated answer to the second question can help explain the first. Let’s dive in.

WHY DOES THE AFFORDABLE CARE ACT NEED TO BE REPLACED?

There might not be a more politically divisive piece of legislation in the twenty-first century thus far than the Affordable Care Act. For some, the entire concept of the bill was flawed, and they opposed it from the very start. More opposed it as certain elements of the bill didn’t turn out quite as expected.

Most Americans actually agree that Obamacare has problems and something has to change. There’s a lot of discussion about those problems that we won’t get into here, as we’ve talked about them in multiple previous articles, including this articlethis one, and this one.

The disagreement—mostly along partisan lines—is whether that “change” consists of a fix, update, or alteration to the existing law, or its complete repeal and replacement with something entirely new.

In this regard, Congress finds itself in an interesting position. While American voters have presumably handed them the means to repeal Obamacare through what many pundits agree was an electoral mandate, many polls—including this one from the Kaiser Family Foundation—show that Obamacare is actually viewed much more favorably than at any point since it was originally passed.

In fact, one poll from USA Today found that 53% of Americans think Congress should either leave Obamacare alone or work on fixes within the bill’s framework.

Currently, both chambers of Congress are moving forward with a repeal-and-replace plan. Let’s talk about that.

WHAT’S IN THE AHCA (AND BCRA)?

The AHCA legislation passed by the U.S. House includes many changes to Obamacare:

  • It would eliminate the individual mandate to carry health insurance, replacing it with a 30% premium hike of 30% for those who re-enroll in health insurance after not carrying it for at least 63 days.
  • It would cap Medicaid payments and lower the income ceiling to qualify for Medicaid.
  • It would repeal taxes on high-income taxpayers and insurers that were in part used to pay for Obamacare’s provisions.
  • States could apply for waivers to receive exemptions from the law’s mandate—carried over from the ACA—that insurers cannot deny coverage based on pre-existing conditions.
  • It’d provide money to health insurers to bring some stability to premiums while establishing a high-risk pool.

(You’ll note that we correctly predicted some of these facets of the bill in our January post on this subject!)

The Better Care Reconciliation Act of 2017 is currently being debated by the U.S. Senate. In many ways, it has the same ideas behind it as the already-passed ACHA, although details differ.

The Congressional Budget Office—which releases nonpartisan accounting information about legislation being considered by Congress—has noted that the Senate’s plan would leave 22 million more people uninsured by 2026, but would cut federal deficits by $321 billion over the next decade. According to the CBO, 15 million of those people would be left uninsured by the aforementioned shrinking of Medicaid.

AN UNPOPULAR REPLACEMENT PLAN

There’s no way to sugarcoat this: the plan proposed as the replacement to Obamacare—the American Health Care Act of 2017, or AHCA—is deeply unpopular. Even with a margin for error in polling and the condition “as-is” noted, 8% support for a such a pivotal piece of legislation is a rough obstacle. The House plan, according to one poll, approached 50% disapproval.

Why is it so unpopular? As we’ll get into in a second, the legislation has opponents on both the left and the right.

Currently, moderate Republicans and their conservative peers in Congress are at an impasse. Moderates such as Susan Collins (R-ME) oppose the bills in its current form, citing their concerns over the number who would be left uninsured by the legislation, particularly in the form of cuts to Medicaid. On the other end of the spectrum, conservatives such as Ted Cruz (R-TX) don’t believe the Senate bill goes far enough to remove Obamacare.

But, the House plan passed. Why can’t the Senate version also get through?

Such worries proved inconsequential in the U.S. House, where Republicans enjoy a 238-193 majority over Democrats, and were able to weather 20 “No” votes from their own party (and one abstaining vote) and still pass the bill by a 217-213 margin.

However, in the U.S. Senate, Majority Leader Mitch McConnell (R-KY) is only working with a 52-48 lead. This means that he can only weather two senators defecting, and even that would require a tie-breaking vote from Vice President Mike Pence.

To give you a sense of the uphill battle McConnell faces, there are currently 10 Republican senators who have come out in opposition to the current bill. This is a tightrope: if he moves the bill further to the right to appease conservatives, moderate Republicans will dig in their heels and vote no. Same thing in reverse.

With no Democrats expected to vote for the repeal-and-replace plan, McConnell will need to thread the needle on a bill that will fundamentally remake as much as one-sixth of the nation’s economy. High stakes, indeed!

WHY DON’T REPUBLICANS JUST REPEAL OBAMACARE FIRST?

With McConnell’s work stalled, straight repeal without the messiness of replacement is an idea that some frustrated Republicans—including President Trump—have suggested via press conferences and—as you might expect—early morning tweets.

President Trump has tweeted the idea to repeal Obamacare and then replace it later.

Ever the negotiator, Trump seems to be hedging his bets with this particular attempt to repeal Obamacare. While he started as an enthusiastic supporter of the Senate’s attempt to get the job done, he has since retreated, noting that should the Senate’s attempt fail, Congress would be better off repealing the Affordable Care Act now and figuring out the way forward later.

But, that, too, is a hard sell. Repealing Obamacare without a plan for replacement legislation would likely throw the healthcare markets into crisis. Insurers hate unpredictability, and there’s nothing more unpredictable than pulling the tablecloth from underneath the fine china and hoping everything lands upright and unbroken. According to some estimates, premiums could rise 25% in the first year and double by 2026, while 32 million people would lose health insurance.

For these reasons, repeal-without-replacement is also pretty unpopular. Only 30% of registered Republicans support it, with only 19% of Americans overall backing such a move.

SO, WHAT’S NEXT?

McConnell really wanted to get the plan to repeal Obamacare done by Independence Day. Now, Congress has adjourned for recess and senators are returning to their home states, where the collective furor over the healthcare debate—on both sides—has reached a fever pitch as hot as the weather outside.

Many pundits believe that talking with passionate constituents will only convince the conservative and moderate factions of Republicans to dig in their heels further.

One possible outcome is that McConnell realizes he can’t get a bill passed and the Senate goes in a different direction. Some have suggested that moderate Republicans and Democrats might work together on legislation to fix many struggling areas of the Affordable Care Act, but otherwise leave Obamacare intact. Such a bill would still have to get through the House and earn Trump’s signature, so that might not be a likely course of action.

Via Twitter, President Trump has endorsed the potential that the ACA may be allowed to continue if Republicans fail to repeal-and-replace through the AHCA.

Others, including President Trump, have floated the idea of doing nothing and letting Obamacare fail on its own.

Yet, for those hoping for a repeal Obamacare victory this summer, there’s a glimmer of hope. McConnell is known throughout the Senate as a shrewd negotiator who knows how to muster votes in the unlikeliest of places. Obamacare repeal-and-replace isn’t dead yet.

We recommend buckling up: it’s going to be quite a ride over the next few months. We’re fascinated to see how things turn out.

WE’RE YOUR SOURCE FOR HEALTHCARE POLICY ANALYSIS

Here at FBC Insurance, Benefits & Consulting, we’re experts on the Affordable Care Act and the intersection of healthcare legislation, policy, and markets.

As one of Arizona’s oldest and largest locally owned insurance and benefits consulting firms, FBC helps more than 300 major employers throughout the United States with their healthcare needs.

We’re all about solving the risk puzzle for our clients. That’s why we pride ourselves on keeping up-to-date with developments in healthcare taking place in Washington, New York, and right here in Arizona.


Learn more about us or give us a call at (602) 277-8477