Vice President-elect Mike Pence and the top Republicans in Congress made clear on Wednesday, more powerfully and explicitly than ever, that they are dead serious about repealing the Affordable Care Act.
How they can uproot a law deeply embedded in the nation’s health care system without hurting some of the 20 million people who have gained coverage through it is not clear. Nor is it yet evident that millions of Americans with pre-existing medical conditions will be fully protected against disruptions in their health coverage.
But a determined Republican president and Congress can gut the Affordable Care Act, and do it quickly: a step-by-step health care revolution in reverse that would undo many of the changes made since the law was signed by President Obama in March 2010.
Step 1: Defang the filibuster
The Senate intends to pass a budget resolution next week that would shield repeal legislation from a Democratic filibuster. If the Senate completes its action, House Republican leaders hope that they, too, can approve a version of the budget resolution next week. Whether they can meet that goal is unclear.
The resolution contains seemingly innocuous language, instructing four committees that control health care policy — two in the Senate, two in the House — to draft legislation within their jurisdiction that would cut at least $1 billion from the deficit over 10 years. But that language has real teeth. The legislation produced to meet those instructions can pass the Senate with a simple majority — 51 votes if all senators are present — obliterating the power of the Democratic minority to block it.
Those four committees would have just a few weeks, until Jan. 27, to produce legislation repealing major provisions of the Affordable Care Act. House Republicans have some practice at this, because they have voted more than 60 times since 2011 to repeal some or all of the law.
The budget blueprint will guide Congress but will not be presented to the president for a signature or veto.
Step 2: Add the details
The committees — House Energy and Commerce, House Ways and Means, Senate Finance, and Senate Health, Education, Labor and Pensions — will quickly assemble legislation intended to eviscerate the health care law.
The repeal legislation will be in the form of a reconciliation bill, authorized by the Congressional Budget Act of 1974. Such bills can be adopted under special fast-track procedures. But Senate rules generally bar the use of those procedures for measures that have no effect on spending or revenue. So the legislation, as now conceived, would probably leave the most popular provisions of the health law intact, such as the prohibition on insurers’ denying coverage to people with pre-existing conditions.
Instead, the legislation would:
– Eliminate the tax penalties imposed on people who go without insurance and on larger employers who do not offer coverage to employees.
– Eliminate tens of billions of dollars provided each year to states that have expanded eligibility for Medicaid.
– Repeal subsidies for private health insurance coverage obtained through the public marketplaces known as exchanges.
It could also repeal some of the taxes and fees that help pay for the expansion of coverage under the Affordable Care Act. But some Republicans have indicated that they may want to use some of that revenue for their as-yet-undetermined plan to replace the health care law.
The 2010 law imposed taxes and fees on certain high-income people and on health insurers and manufacturers of brand-name prescription drugs and medical devices, among others. Republicans have not said for sure which taxes they will scrap and which they may keep.
Republicans say they will delay the effective date of their repeal bill to avoid disrupting coverage and to provide time for them to develop alternatives to Mr. Obama’s law. They disagree over how long the delay should last, with two to four years being mentioned as possibilities.
Step 3: The new president’s role
Within days of taking office, President-elect Donald J. Trump plans to announce executive actions on health care. Some may undo Obama administration policies. Others will be meant to stabilize health insurance markets and prevent them from collapsing in a vast sea of uncertainty.
“We are working on a series of executive orders that the president-elect will put into effect to ensure that there is an orderly transition, during the period after we repeal Obamacare, to a market-based health care economy,” Mr. Pence said at the Capitol on Wednesday.
He did not provide details, and Trump transition aides said they had no information about the executive orders. But some options are apparent. The federal government could continue providing financial assistance to insurance companies to protect them against financial losses and to prevent consumers’ premiums from soaring more than they have in the last few years.
Step 4: Find a replacement
Even as they move full speed toward gutting the existing health law, Republicans are scrambling to find a replacement. At the moment, they have no consensus.
Mr. Pence said on Wednesday that the replacement would probably encourage greater use of personal health savings accounts and make it easier for carriers to sell insurance across state lines. Also, he said, it would encourage small businesses to band together and buy insurance through “association health plans” sponsored by business and professional organizations.
Some type of subsidy or tax credit for consumers, to help defray the cost of premiums, is also likely. States would have more authority to set insurance standards, and the federal government would have less.
Mr. Trump has also endorsed the idea of state-run “high-risk pools” for people with pre-existing conditions who would otherwise have difficulty finding affordable coverage.
Many experts have said that repealing the health law without a clear plan to replace it could create havoc in insurance markets. Doctors, hospitals and insurance companies do not know what to expect.
Without an effective requirement for people to carry insurance, and without subsidies to buy it, supporters of the law say many healthy people would go without coverage, knowing they could obtain it if they became ill and needed it.
Democrats in Congress say they will do everything they can to thwart Republican efforts to dismantle the Affordable Care Act. They plan to dramatize their case by publicizing the experiences of people whose lives have been saved or improved by the law.
In the Senate next week, Democrats will demand votes intended to put Republicans on record against proposals that could protect consumers. Defenders of the law also hope to mobilize groups like the American Cancer Society and the American Heart Association to speak up for patients.
The Senate Democratic leader, Chuck Schumer of New York, and the House Democratic leader, Nancy Pelosi of California, are encouraging their colleagues to organize rallies around the country on Jan. 15 to oppose the Republicans’ health care agenda.
And to buttress their case, Democrats are compiling statistics from the White House and from researchers at liberal-leaning groups like the Center on Budget and Policy Priorities, the Commonwealth Fund and the Urban Institute, which warn of catastrophic consequences if the law is repealed.