WASHINGTON—President Donald J. Trump and House Republicans are pressing forward with a high-risk strategy to repeal and replace the Affordable Care Act (ACA), disregarding the views of medical professionals and potentially imperiling the party’s political future in conservative states, where many voters stand to lose their health care.
The effort could cause upheaval in a roiled insurance market next year, as Republicans face voters for the first time with Trump in the White House—though that turmoil would happen only if the plans manage to clear a divided Senate.
Trump is showing only a tenuous grasp of the legislative process and mercurial leadership in rounding up support. But Republicans who spent seven years promising to scrap President Barack Obama’s signature domestic achievement say their strategy is worth the risk.
“If you ask someone to give up something, there will be resentment,” said Rep. Michael C. Burgess, Republican-Texas, and chairman of the Energy and Commerce subcommittee on health. But, he added, “If that claims my congressional career, so be it. It will be worth it to me to have effected this change.”
The risks mounted steadily this past week. The insurance and health-care industry cited likely damage to medical coverage for millions
of Americans.
Conservatives fought the bill on the grounds that it did too little to reduce subsidies. And House leaders moved forward even though the influential Congressional Budget Office has yet to assess the costs or effectiveness of the plan.
Ultimately, Republicans are counting on Democrats to step in and help repair what even Republicans anticipate as upheaval if a repeal measure is passed without a broad remake of US health care.
Republican leaders have made no effort to hide the strategy. House Speaker Paul Ryan spoke at length this past week about a three-stage effort: First, with only Republican votes, repeal major parts of the health law and put in place some new provisions.
Second, let Health and Human Services Secretary Tom Price use regulatory powers to try to stabilize insurance markets. Third, pressure Democrats to help with a series of bills to complete the replacement and change the health-care system more to the liking of conservatives.
But that bet carries enormous peril for consumers and insurers—and congressional Republicans and the Trump administration.
Democrats, eyeing potential turmoil in the run-up to the 2018 midterm elections, have little political reason to cooperate.
“One thing is clear,” said the House Democratic whip, Rep. Steny Hoyer of Maryland. “House Republicans are going to have to find the votes on their own to dismantle the protections incorporated in the Affordable Care Act that the American people now have.”
A growing chorus of Republican policy experts and senators are pleading to slow the process down—or risk a political blood bath.
But Republican leaders and Trump appear to be laying the groundwork for blaming the law they are annulling for the fallout likely to come in the repeal’s wake.
Trump asserted last Friday that 2017 would be “a disaster” for the health law. “That’s the year it was meant to explode, because Obama won’t be here,” he said, adding that “as bad as it is now, it’ll get even worse.”
Last Saturday he wrote on Twitter: “ObamaCare is imploding and will only get worse. Republicans coming together to get job done!” Vice President Mike Pence traveled to Louisville, Kentucky, last Saturday to assure residents that “the Obamacare nightmare is about to end.”
What is clear is that 2018—a year that Republicans say will be messy—will loom large for them as they move toward a vote on the measure. But Republicans say that gives them nearly a year of time, since people will experience few changes with their health care in 2017.
Under the proposed House legislation, individuals would no longer be subject to a penalty if they go without health insurance, a politically popular change that would be retroactive to 2016.
But they would still enjoy the protections of the ACA: Insurers would have to offer a suite of essential health benefits, could not deny them coverage because of preexisting conditions and could not impose annual or lifetime caps on coverage.
Insurers would be free to raise their premiums to meet these requirements, but because current policies are locked in for the year, voters would not see the effects until 2018. If young, healthy Americans flee the market, freed from the mandate, premiums could soar next year.
Insurers say this is a recipe for havoc. Eliminating the penalties used to enforce the mandate that most Americans have insurance “would add to short-term instability in the market,” said Marilyn B. Tavenner, chief executive of America’s Health Insurance Plans, a lobby for insurers.
Instead of the current tax penalty for failing to secure coverage, the bill would introduce a penalty for purchasing insurance after letting coverage lapse: To encourage people to maintain “continuous coverage”, insurers would impose a 30-percent surcharge on premiums for people without coverage for 63 days or more.
But that provision would not take effect until 2019—again leaving 2018 unprotected.
All of that has created immense uncertainty for insurers, which have until June 21 to notify the government if they intend to participate in the federal insurance marketplace next year.
“The current uncertainty makes it difficult to assess what our product offerings for 2018 might be,” said Roy D. Vaughn, a senior vice president of BlueCross BlueShield of Tennessee, which lost more than $400 million in the federal insurance exchange in the past three years. “All options are on the table for 2018.”
For all those worries, the Republicans’ repeal campaign did gain momentum this past week as two House committees approved the legislation, with the full House expected to take it up later this month. Trump praised the legislation, even as it was harshly criticized by doctors, hospitals, insurers and state officials, who said it could increase the number of uninsured and destabilize insurance markets.
The Congressional Budget Office is expected to render its verdict on the legislation this week, with an estimate of the bill’s costs and its effect on coverage, and Republicans are bracing for bad news.
Image credits: Aaron Borton/The New York Times