Previously-hidden divisions within the GOP over the Affordable Care Act are breaking into public view as the party that holds the White House and both houses of Congress grapples with fulfilling its six-year-old promise to scrap the landmark health law.

Differences of opinion over how far the ruling party should go in rolling back all of the provisions of the law have existed for a while. The symbolic repeal bill that Congress passed last year –– and which President Obama vetoed –– was partially shaped by hesitation among some GOP members of Congress about the immediate effects of total repeal on their constituents who had gained coverage through the ACA.

As a result of those concerns, the repeal bill that Congress approved last year aimed at gradually phasing out the marketplace and the Medicaid expansion –– until Congress could come up with a replace, GOP leaders said at the time.

Now that the GOP’s repeal efforts are no longer merely academic, members of Congress are confronting the harsh reality that coming up with an alternative to the ACA that is going to leave current ACA beneficiaries satisfied is not going to be easy.

President-elect Trump has suggested that he will keep in place protections for people with pre-existing conditions as well as allowing people to stay on their parents’ insurance until they’re 26. That pledge makes sense politically –– both provisions are popular –– but how the government can maintain the pre-existing conditions law while repealing the requirement that people purchase insurance is likely economically infeasible.

Chris Jacobs, a former Republican health policy aide on Capitol Hill, tells the Wall Street Journal that many members of Congress likely never anticipated having to forge ahead with repeal. Now, he says, they will have a hard time opposing the same bill they voted to support last year.

“Conservatives successfully fought last year to expand the scope of the (repeal bill) considered by Congress—a bill that was ultimately supported by the overwhelming majority of Republicans in both chambers,” he says. “For that reason, that legislation should serve as the minimum baseline for repeal efforts in the coming year.”

Another major issue confronting Republicans is how they intend to pass whatever repeal legislation they come up with.

They have said throughout the campaign that they want their solution to be the product of bipartisanship, but with Democrats holding enough seats in the Senate to easily block typical legislation via filibuster, Republicans may have to resort to the same legislative tactics that they denounced Democrats for using to pass the ACA in 2010.

If they hope to evade a Senate filibuster, the easiest way for Republicans to pass a bill would be to go through “reconciliation,” by which a budget bill that is deemed to reduce the deficit is exempt from the typical rules that govern Senate debate. Debate is strictly limited and cannot be indefinitely blocked, as is the case with most other legislation.

Instant Insights /

With ACA, Congress will find itself in difficult position

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