“Repeal and replace” is out. The new GOP talking point about the Affordable Care Act is going to be “repeal and transition.” It is part of a coordinated effort to make the evisceration of the biggest piece of social policy legislation in half a century sound a little kinder and a lot gentler, especially to the millions of folks who directly benefit from it. Republican pollsters are privately testing various permutations of the message, and outside allies – from the insurance industry to conservative think tanks – are already starting to embrace the new phraseology being pushed by party chieftains.
— Donald Trump said he would “completely repeal” the Affordable Care Act soon after taking office and immediately “replace” it with something “terrific” that is “so much better, so much better, so much better.” In his first post-election interview, on “60 Minutes,” Lesley Stahl asked what happens if the law gets repealed but not immediately replaced. “No, we’re going to do it simultaneously,” the president-elect insisted. “It’ll be just fine!” But the cold hard math and the rules of the Senate mean that it’s not just fine.
— Georgia Rep. Tom Price’s selection as secretary of health and human services has been widely covered by the media as a signal that Trump intends to make good on his promise to quickly repeal and replace. But talk to the key Republicans in Congress, and you get a different vibe than what you see on the news. Shifting from campaign mode to governing mode, the leaders in both chambers are hurriedly trying to tamp down expectations. The mantra now is that the process to truly get rid of ACA will be a long slog – not a short sprint – and they’re maneuvering behind the scenes to get Trump’s transition team on the same page.
— Here’s the rub: Republicans actually can repeal Obamacare somewhat easily using the procedure known as reconciliation. It’s the same maneuver that Democrats used to jam through the law in 2010 after Scott Brown unexpectedly won a special election to replace the late Ted Kennedy. Only 51 votes are required. But, under the rules of reconciliation, a replacement of the law cannot be moved through this same process. Sixty votes will be required in the Senate for that, and Republicans only have 52 seats.
“Repealing is easier and faster because that is getting to 51 votes. Replacing is going to take 60 votes,” House Majority Leader Kevin McCarthy explained Tuesday during a live interview with The Daily 202. “We’ll repeal Obamacare. It’s replacing Obamacare that you have to make sure you get right. You want to make sure you replace it properly.”
— The emerging Republican stratagem is to create some “transition period,” as McCarthy calls it, setting a firm date on which the law would expire. That would then create a metaphorical cliff that the country would go over unless Congress acts. With the prospect of 20 million Americans losing health insurance coverage, the R’s bet that the D’s will cave and accept something they don’t like rather than nothing at all. As McCarthy put it, “Once it’s repealed, why wouldn’t they be willing to vote for a replacement? Right? You have no other options.”
— This might be a brilliant stroke. Or, if history is a guide, it could fail spectacularly. Chuck Schumer, the incoming Senate Minority Leader, says his caucus won’t budge and pledges resistance. Democrats feel like Republicans never worked with them during the past eight years, and there is heavy pressure from the left flank of Schumer’s caucus to replicate Sen. Majority Leader Mitch McConnell’s strategy of obstruction now that they’re going into the wilderness. It’s a dangerous cycle that could set up an epic game of chicken.
Remember, sequestration was never supposed to actually happen. The idea in 2011 was that the threat of painful cuts to both defense and social programs would be a big enough stick to incentivize Republicans and Democrats on the so-called “supercommittee” to work together on a grand bargain. It was a strategic blunder by both sides.
— Something to ponder: Which eight Democratic senators would actually vote for a replacement to Obamacare? McCarthy thinks incumbents up for reelection in 2018 in red states like Indiana, North Dakota, West Virginia and Missouri will play ball and push their colleagues to do the same. He also thinks Schumer will be temperamentally more willing to cut a deal than Harry Reid would have been, despite whatever he is saying in public.
— Another wrinkle: There is not Republican consensus on what a full replacement package should look like. There was much discussion when it looked like the Supreme Court would undercut the foundation of Obamacare with the decision in King v. Burwell about what fixes conservatives could get behind. But the justices sided with the government, so the issue never came to a head. “It’s not easy,” McCarthy acknowledged. “I’ve sat around the room trying to come up with the replacement plan.”
— To be sure, Tom Price has introduced his own legislation to replace the ACA four times, and in 2015, the House Budget Committee chairman was the chief sponsor of the only ACA-repeal bill to ever reach the White House. The president vetoed it, of course. And it is important to note that the Price alternative is quite partisan and leave no real room for negotiation with Democrats. If Republicans use it as an opening bid, the best case scenario is that the other side reads it as an unserious joke. The worst case scenario is that they take it as an insulting slap and then refuse to even come to the table.
— Another player to watch: Trump also named Seema Verma as the administrator of the Centers for Medicare and Medicaid Services Wednesday. She designed the most far-reaching Medicaid experiment under the law that the Obama administration has ever allowed. She’s also worked closely with Gov. Matt Bevin in Kentucky as he worked to overhaul his state’s set-up.
— McCarthy believes there is close to universal support among Republican lawmakers for protecting people with pre-existing conditions and to let children stay on their parents’ plans until they are 26 (which does not actually cost insurers all that much). Trump endorsed both elements during the post-election “60 Minutes” sit-down.
— They didn’t get as much attention as his Tweets, but Trump made some pretty specific pledges related to health care during the campaign. Americans will get “great health care at a fraction of the cost,” he declared this fall. “Insurance costs will go down, and consumer satisfaction will go up! . . . You will be able to choose your own doctor again!”
Each of the following six commitments from Trump is on video tape: promising to eliminate the individual mandate, allowing individuals to fully deduct their health insurance premium payments on their taxes, letting people buy insurance across state lines, dramatically expanding the use of Health Savings Accounts, bringing down prescription drug prices by importing cheaper medications from overseas and allowing Medicare to negotiate drug prices directly with the manufacturers.
— Senate Finance Committee Chairman Orrin Hatch, who has jurisdiction over federal health care programs, now says it will take up to three years to repeal the Affordable Care Act – a timeline that would guarantee the law is once again a marquee issue in the 2018 and 2020 elections. “We know that to correct it is going to take time,” the Utah senator told Kelsey Snell yesterday afternoon. “I don’t see any reason for anybody to be too upset about it.”
— Wise Republicans are trying to get out front of what they see as inevitable voter backlash if they run roughshod with reconciliation, without trying to win Democratic buy-in (or at least making a show of trying to). “There will be a multiyear transition into the replacement,” Senate Majority Whip John Cornyn, R-Texas, said in a separate conversation with Kelsey. “This is a failed piece of legislation and it is coming apart at the seams, but it is going to take us a while to make that transition from the repeal to actually replacing it.”
— Wisconsin is a telling examplebecause it is the home state of both the Speaker of the House and the incoming White House chief of staff. About a quarter of a million people there are enrolled in the Obamacare exchanges, and another 143,000 childless adults are enrolled in Medicaid because of the 2010 law. “We believe that the transition should be a reasonable time, whether it’s a year, a year-and-a-half or two years,” Scott Walker, the new chairman of the Republican Governors Association, told the Milwaukee Journal Sentinel.