Republicans in Congress have insisted the only way to fix Obamacare is to repeal it. But with Barack Obama about to leave the White House, several Republicans sound willing to tweak it rather than kill it.

These Republicans suggest that a Hillary Clinton presidency could shift the debate over the Affordable Care Act just enough to work on improvements with someone who isn’t the law’s namesake.

And it’s not just politics: Last week’s decision by one of the nation’s largest insurers, Aetna Inc., to withdraw almost entirely from the program’s insurance exchanges is the latest warning sign that Washington may have to act to prevent the law from unraveling. Many of the areas most affected by a potential loss of coverage are represented by Republicans.

Representative Scott DesJarlais, a Tennessee Republican and a doctor who has strongly backed Donald Trump, said his party would "certainly" consider a Clinton plan to revise a law he says is in a death spiral.

"She would be able to to look at what has failed," he said in an interview. "Obviously, we wouldn’t be closed-minded. The bottom line is, how do we take care of people and make it affordable for them?"

Pete Sessions, a Texas Republican who runs the influential House Rules Committee, said he remains opposed to the health-care law, but he also conceded that it’s unlikely, for both political and financial reasons, that the law could be repealed outright.

Obama’s departure, he said in an interview, will be "an opportunity to see there are other ideas, not just that there’s a continual battleground."

Most Republicans still insist Obamacare must go, and a Trump presidency would all but guarantee much bigger change because he too has called for its repeal.

But faced with a Democratic president and a possible Democratic Senate, some Republicans see an opening to make the law more to their liking, particularly because the party has never coalesced around a replacement.

More than half a decade after Democrats passed the health law without any Republican votes, Obamacare is showing its seams. Enrollment in coverage sold through new government-run insurance exchanges has lagged expectations. The nation’s largest commercial insurer by market value, UnitedHealth Group Inc., has joined Aetna and several smaller companies in retreating from the program. Insurers that remain complain that patients are sicker and costlier than they expected, and that provisions in the law intended to prod young people to sign up are toothless or haven’t been enforced.

Little consensus

Fixing the law won’t be easy, as there’s little consensus on what should be changed.

Many of the insurance industry’s top suggestions, such as lowering premiums for young people and raising prices for older customers, are opposed by consumer advocacy groups. The possibility looms large that any legislation could become mired in the same partisan warfare that almost halted the Affordable Care Act itself.

But Clinton may succeed at convincing Congress to act by virtue of not being named Obama. The tactics the president employed to pass the health law, including passage of a companion bill under procedures that prevented a Senate filibuster, enraged and alienated Republicans, preventing him from negotiating any meaningful changes later.

AshLee Strong, a spokeswoman for House Speaker Paul Ryan, a Wisconsin Republican, said that a plan to repeal and replace the Affordable Care Act -- included in the six-part House Republican agenda that Ryan calls "A Better Way" -- remains the party’s position. But she added: "The speaker has said we’re a party of ideas."

Ryan has endorsed Trump for president. Clinton, however, holds about a seven percentage-point lead on Trump in an average of national polls maintained by the Pollster.com website.

Clinton’s proposals

Clinton has proposed changes to the Affordable Care Act, including more generous subsidies to offset rising premiums and a new tax credit for deductibles, co-payments and other out-of-pocket expenses, the subject of frequent complaints by patients, notes Jesse Ferguson, a spokesman for Clinton’s campaign. She also supports creating a new government-run insurer, known as the "public option," to increase consumers’ choices in areas where private plans have withdrawn.

In negotiations with Congress, though, Clinton would have to navigate both Republican demands that she may find unpalatable and the conflicts between insurers and consumer advocates.

"Compromise is not really that bad of a word. But to continue to simply do nothing is bad," Representative Dennis Ross, a Florida Republican, said in an interview. "Just continuing this standoff, just leaving it alone, is going to make it worse for the American people."

Demanding concessions

Republicans may demand concessions from Democrats in exchange for agreeing to Clinton’s amendments to the law. A likely target would be the law’s unpopular requirement that most Americans carry insurance and that most employers provide it.

"The individual mandate doesn’t work," said Joe Antos, a health-care economist with the American Enterprise Institute who opposed passage of the health law but now supports fixing it, rather than repeal. "If it did, most of these problems wouldn’t exist."

Sessions introduced legislation in May with Senator Bill Cassidy, a Louisiana Republican, that would repeal only the Affordable Care Act’s individual and employer mandates, while setting up an alternative system of insurance subsidies that Sessions says could co-exist with Obamacare.

Clinton would probably regard the Sessions-Cassidy legislation, titled the World’s Greatest Health Care Act of 2016, as little more than a stealthy attempt to undermine the Affordable Care Act. Nonetheless, "I think she would want to call us," Sessions said in an interview.

Insurers’ problems

Insurers, meanwhile, want Washington to make it easier for them to turn a profit on Obamacare plans. On top of charging younger customers less and older ones more, the industry would like to be allowed to offer cheaper plans with less generous benefits, and it wants the government to crack down on people who try to sign up for coverage outside of the law’s annual enrollment periods, who are thought to often be sick and in immediate need of expensive health-care services.

Such customers may be "buying insurance when the house is on fire," Karen Ignagni, the president and chief executive officer of EmblemHealth, New York’s largest insurer, said in an interview.

She said her company and others also want revisions to a program called "risk adjustment" that requires insurers who sign up Obamacare customers who are relatively healthy to pay money to plans with relatively sicker patients. The program has at times resulted in smaller insurers owing millions of dollars to larger competitors.

"I can’t recall a law being passed that isn’t after a few years adjusted and modified to fit circumstances as they develop," Ignagni said. She previously led America’s Health Insurance Plans, the industry’s Washington lobbying group.

But some of the industry’s proposals will run into opposition by consumer advocates that strongly support Obamacare and express skepticism that insurers are in much distress.

"I don’t believe we have a crisis, notwithstanding the latest news about Aetna," Ron Pollack, the executive director of the consumer advocacy group Families USA, said in an interview. "I think it is essential that we use whatever dollars that are available as effectively as possible. Padding insurance company profits does not fit within that concept."

Pollack said his group supports "improvements to the health-care system," including many of Clinton’s proposals. He’d also like to see the government require insurers to offer standard plans in the exchanges that would be easier for customers to understand and compare. "The most pressing item right now relates to affordability," he said.

Conservative opposition

Any major overhaul of Obamacare would face obstacles in Congress. Importantly, even if Republican leaders were receptive, they and Clinton would have to contend with conservative Republicans in the House who have led the repeal-and-replace refrain.

It’s also unclear who would lead negotiations. Fred Upton of Michigan, the current chairman of the House Energy and Commerce Committee, which has jurisdiction over much of Obamacare, faces a term limit in that post. Unless he receives a waiver, the panel will have a new leader next year, perhaps John Shimkus of Illinois or Greg Walden of Oregon.

House Budget Committee Chairman Tom Price of Georgia, a medical doctor, refused to speculate about whether congressional Republicans might have to find some way to work with a Democratic president next year to fix the health-care law.

"It needs to be repealed, not the least of which is because the premise is the federal government knows best on health care," he said in an interview. "That’s just a step in the wrong direction out of the chute."

Instant Insights /

Clinton win could pressure GOP to heal, not repeal, Obamacare

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