An effort to replace the ACA could put Sen. Charles Schumer, seen here, in the front seat. (Photo: AP Images)

Both the Congressional Budget Office and President-elect Donald Trump may be putting pressure on congressional Republicans to work with Democrats to come up with an Affordable Care Act replacement bill, not just de-fund ACA spending programs.

Trump, who is set to take the oath of office Friday, said in a weekend interview with the Washington Post, which is posted behind a login wall, that he wants Congress to replace the ACA with a program that provides “insurance for everybody.”

He also said he would use the power of the presidency and Twitter if Congress gets cold feet and is slow to pass an ACA replacement plan.

The Congressional Budget Office, meanwhile, posted a grim analysis of the effects of an ACA de-funding proposal.

Because of the way the Senate rules work, Republicans can probably get a measure that would kill major ACA spending programs, such as the ACA premium tax credit program and the cost-sharing reduction program, through Congress without help from Democrats. But they probably need at least eight votes from Democrats and independents in the Senate to pass a bill that would repeal all of the ACA, or replace the ACA.

Some Republicans have proposed de-funding the ACA quickly, and then trying to change or replace the law later.

If an ACA de-funding proposal became law, and no other ACA changes occurred, de-funding of the ACA premium tax credit subsidy and cost-sharing reduction subsidy would probably increase the number of people who were uninsured by 18 million in the first new plan year following the effective date of the de-funding effort, and it would probably increase premiums for individual major medical coverage by 20 percent to 25 percent, the CBO analysts predict.

The cost of individual health coverage would increase sharply whether consumers bought the coverage through an ACA public exchange or outside the exchange system, the analysts predict.

By 2026, if the ACA de-funding measure and other laws stayed in place, unchanged, the total number of uninsured people would be 32 million higher than if the ACA stayed in place, and individual major medical premiums would be about twice as high, the analysts predict.

Market withdrawals would eliminate access to individual health coverage for about half of Americans in the first year after the end of ACA subsidies took effect, and for about three-quarters of Americans by 2026, the analysts predict.

Byrd Rule barrier

ACA critics could have trouble getting any ACA measure other than an ACA de-funding measure through the Senate because Republicans have only 52 votes in the Senate.

ACA critics can pass a budget measure that changes ACA spending and revenue provisions with 51 votes, but, under Senate rules, ACA opponents appear to need 60 votes to pass any bill that fully repeals the ACA, changes ACA provisions other than budget-related provisions, or replaces the ACA.

Trump and other ACA critics might, however, be able to force a full ACA repeal bill or ACA replacement bill through the Senate by ignoring the advice of the Senate parliamentarian on whether an ACA-related budget measure is really related to the federal budget. In the past, Senate leaders have taken the advice of the parliamentarian about whether measures relate to the budget, but it’s possible ACA critics could depart from tradition.

If ACA critics choose to stick with tradition and follow the advice of the parliamentarian, they will likely need to work closely with Senate Minority Leader Charles Schumer to develop an ACA change proposal that could attract the votes of at least eight Senate Democrats and independents, and at least one additional Democrat or independent for each Republican senator who votes against the results of the negotiations.

Schumer has been highly critical of Trump in recent weeks. But as recently as 2008, Trump hosted an event that Schumer organized to raise money for Democratic Senate candidates.