Despite repeated assurances from Republicans that their first order of business under a Trump administration would be the repeal of the Affordable Care Act, here it is halfway through February and there hasn’t been much progress on that front.
Partly that’s due to President Trump’s insistence that repeal and replacement of the ACA with something “much better” happen pretty much simultaneously, but other reasons delaying specific actions toward repeal include the Republicans’ lack of a replacement plan and substantial outcries against repeal — or at least against repeal of specific provisions of the ACA, such as prevention of denial of coverage due to preexisting conditions and allowing children up to 26 years old to stay on their parents’ plans.
And therein lies the rub. There’s plenty of disagreement in Congress about whether to repeal certain provisions of the law, how to repeal others without crashing the insurance market (or getting thrown out of office for depriving millions of health care coverage) and how to pay for coverage while still delivering promised tax breaks that Republicans are determined to provide.
As the debate continues over these and plenty of other concerns about the ACA, The Hill has pointed out 10 players who could have the biggest influence on the process.
10. Senator Lamar Alexander, R-Tenn.
Alexander, the chairman of the Senate Health Committee, is cautioning fellow Republicans not to rush into anything, but to “think it all the way through,” according to a Politico report. He’s been pushing more for “repair” than “repeal,” and is wary of the potential for destabilization of the insurance market if action is too hasty — as well as the effect on the public if there isn’t a replacement plan ready to shove into place as soon as repeal takes place.
He’s also indicated that he’s willing to work with Democrats to get the job done, unlikely as that may be, and has even cited a letter from Sen. Tim Kaine, D-Va., offering to work on improvements to the law.
But, said Politico, his slow-and-steady approach is wearing on more impatient Republicans, and “[w]hile the knives have not yet been turned on Alexander, it’s clear the party’s right flank is eager to follow through on its years-long vow to deep-six the health care law.”
9. Representative Mark Meadows, R-N.C.
One representative who may be sharpening his knife is Meadows, a hard-liner anxious to see the ACA gone with or without a replacement in place.
According to another Politico report, Meadows, chairman of the conservative House Freedom Caucus, is pushing for all he’s worth to repeal the ACA even if there’s nothing ready to take its place.
What he proposes instead, is to start with the same stand-alone repeal bill that Congress sent to President Barack Obama in 2016, pass that and add any replacements later. Conservatives’ big fear is that with sufficient delay, some Republicans could chicken out on voting for repeal — one of conservatives’ biggest goals — if time is taken to add any additional provisions to the bill.
“Functionally, [our idea] eliminates some of the excuses for our Senate colleagues; if they voted on this then, there is no reason they can’t vote on it now,” he was quoted saying in the report, adding, “I think a lot of people are looking to some of the policy debates to be an excuse not to vote on repealing the Affordable Care Act.”
8. Secretary of Health and Human Services Tom Price
Price, whose confirmation as secretary was fraught with accusations of insider trading and misrepresentation of information to the committee, actually has a plan to replace the ACA.
But according to a Money report, with his plan relying on refundable tax credits instead of subsidies, his efforts to dismantle bundled plan payments under Medicare and a bigger reliance on health savings accounts, that plan would help wealthier people and make it tougher for seniors and low-income folks to afford coverage — or, for that matter, their share of medical bills, which would be higher. In addition, sicker people would be consigned to high-risk pools.
In addition, a New York Times piece pointed out that his plan to weaken enforcement of the mandate to buy coverage will eventually hurt insurers, too, since that will mean those in poorer health will be the ones to buy — when they can — leaving insurers either to pay higher bills, charge higher premiums or leave the market.
7. Senator Dean Heller, R-Nev.
While Heller is no fan of the ACA, he’s in a tough spot that could ultimately push him in the opposite direction from conservatives desperate for repeal. He was the target of a video supporting the ACA, according to an NBC News report, by the Center for American Progress Action Fund — which has been recruiting people to tell their stories of how the ACA has helped them get coverage in an effort to challenge the repeal push.
In addition, Heller comes up for election in 2018, and although he supports repeal of the ACA Nevada accepted the ACA’s expansion of Medicaid. In fact, during Price’s confirmation hearing, Heller “expressed his worries about people losing coverage if the Medicaid expansion is repealed,” according to The Hill report.
6. Senator Susan Collins, R-Maine
Collins is a centrist, and opposes repeal of the ACA until a replacement is ready — and to top it off, she’s not convinced that defunding Planned Parenthood as part of the repeal is a good idea. Of course that’s on conservatives’ agenda as a prime goal.
But she’s gone farther: together with Senator Bill Cassidy, R-La., she’s introduced a bill that would let states keep the ACA or move to a replacement program. Needless to say, that is unacceptable to conservatives.
Reuters reported that, under the joint bill, states would also be able to keep some funding under the ACA or under the replacement program. One goal of the bill is to find some common ground with any Democrats who might consider voting for the bill — and while so far it’s won no fans on the other side of the aisle, it could signal a crack in the Republicans’ wall.
5. Representative Greg Walden, R-Ore.
Walden’s pushing hard for repeal, although he has introduced a bill with a provision to protect those with preexisting conditions.
That said, his panel, the House Energy and Commerce Committee, is contemplating a bill on March 1. But his job won’t be easy. A Politico report termed him the “Obamacare attack dog,” and he got to where he is on the committee “in part because of his success getting Republicans elected to Congress when he ran the National Republican Congressional Committee in the 2014 and 2016 election cycles.”
Interestingly, now that he’s in the catbird seat, his rhetoric has changed, the report said, with him using terms like “repair” and “rebuild” to indicate his own efforts.
He was quoted in the report saying, “I don’t care what you call it. It needs to be fixed. We need to work aggressively on the repairs to the individual market, to Obamacare. Some might call that replacement. I call that a rebuild. I call it repair.”
4. Senator Rand Paul, R-Ky.
A column in the Los Angeles Times appearing after the introduction of Paul’s ACA alternative offering pointed out that “The few details, or guideposts, or guidelines that they did disclose only underscored how difficult it will be for Trump, Paul and the … Republicans on Capitol Hill to fashion a replacement that meets all their stated goals.” Paul’s plan “centers on a tax credit and expansion of health savings accounts to help people afford health insurance, while repealing the core aspects of” the ACA, The Hill’s report said.
Paul is in favor of a simultaneous repeal/replace, which is what Trump himself is calling for. And while Paul says his plan would “insure the most amount of people, give access to the most amount of people, at the least amount of cost,” there were no specifics on what “the most” or “the least” might be.
He did say that he planned to eliminate the 10 “essential health benefits” required by the ACA for every qualified plan, as well as favoring HSAs and for allowing “individuals to come together in associations to buy insurance,” according to the Los Angeles Times report.
In fact, the report added, Paul intends to “legalize the sale of inexpensive insurance,” which means policies that don’t cover “outpatient services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse treatment, prescription drugs, rehabilitative services, laboratory tests, preventive care and chronic disease management, and pediatric care including dental and vision care.”
And under this “inexpensive insurance,” women will return to being charged extra for pregnancy care.
3. Senator Bob Corker, R-Tenn.
Corker, chairman of the Foreign Relations Committee, isn’t really as enthused about ACA repeal as many of his colleagues; in fact, this month he was quoted in the Huffington Post saying, “To be honest, there’s not any real discussion taking place right now.” And that was after the Republican retreat in January, after which a secret audio revealed that Republicans are actually getting worried about what might happen once the ACA is repealed.
He said in the report that “we’re dealing with something that is very important, very complicated. It’s explosive if not handled properly, and we should take our time and do it right.” And that’s a far cry from what his more conservative brethren are advocating.
Corker is also one of the few Republicans wondering how a replacement plan would be able to function under conservatives’ goal of repealing all the ACA’s tax provisions, since it would leave them without any revenue to fund a replacement.
2. Senator Bill Cassidy, R-La.
In addition to having jointly introduced a replacement bill with Collins, Cassidy is openly advocating a joint repeal/replacement and citing Trump’s preference for doing just that.
In the Politico report, Cassidy said he’d “rather not answer the hypothetical” of how he would vote on an independent repeal bill that did not accompany a replacement plan, but said that that’s what Trump wants so he hopes the Senate will provide it. In the report, he was quoted saying, “I think we need to know where we’re going to end up in a practical way so that when we begin this process we’re heading in that direction.”
He’s also being practical about how to pay for that replacement plan, advocating that ACA taxes must be retained so that there’s revenue to provide for a replacement plan. At the rollout of his plan, he was quoted saying, “The revenue is essential.”
1. Senator Orrin Hatch, R-Utah
Hatch is chairman of the Senate Finance Committee, and as such he has a pretty strong grip on the purse strings. But despite the fact that Hatch is up for reelection in 2018, he’s firmly opposed to keeping any ACA taxes on the books. He was quoted in The Hill report saying, “All of the ObamaCare taxes need to go as part of the repeal process.”
That attitude could be problematic, according to a report at Talking Points Memo, which pointed out that “[h]ealth care experts have warned that scrapping the taxes immediately could significantly restrict any GOP efforts to replace the ACA down the line.”
It continued, “Without the revenue from those taxes, Republicans eventually would have to raise taxes on their own unless, as Hatch’s announcement may be signaling, they don't plan to roll out a significant replacement package at all.”
And that could be the worst news of all for the millions awaiting the fate of their health care coverage.