Trump Victory Puts Obamacare Dismantling Within Reach
By Jennifer Haberkorn Politico November 9, 2016
Donald Trump's ascension to the White House puts President Barack Obama's Affordable Care Act — and health insurance for some 20 million Americans — in grave peril.
Ever since the law passed in 2010, Republicans have campaigned on a pledge to repeal Obama's signature domestic policy achievement. Trump's victory gives them their first opportunity to do so.
Trump and congressional Republicans have set sky-high expectations for repealing Obamacare; he's promised to scrap it "very very quickly." And they have a road map to repeal significant parts of the law, even with a narrow Senate majority. But the GOP is still far apart on specifically what kind of alternative to enact. And it's unclear how the public would respond to taking health care away from millions of people — the first time in American history that such a broad societal benefit enacted by Congress would be repealed.
Trump and House Speaker Paul Ryan have given only broad outlines of what that replacement would look like. They're relatively similar plans: Individuals would get tax credits to help them buy insurance, tax-favored Health Savings Accounts would be encouraged, insurers would be allowed to sell policies across state lines. Neither has filled in details, but there's little doubt about their goals.
Rarely has a law been through so many brushes with death — multiple legal challenges including two potentially lethal Supreme Court cases, three national elections, and dozens of congressional votes for repeal. But Trump's election creates the most potent risk of repeal yet.
But Trump didn't make Obamacare repeal — a mantra of every Republican in an election since 2010 — a focal point of his campaign, even though he stressed it in the final days to motivate his voters to turn out and to ride the negative headlines about premium hikes as the 2017 enrollment season got underway. He didn't give it even a passing mention in his victory speech early Wednesday morning.
That lack of emphasis could help the GOP downplay expectations if they can't quickly repeal the law, and focus on other themes that Trump stressed more consistently on the stump, such as immigration.
"If the candidate were Paul Ryan-esque or Ted Cruz or a more traditional conservative, the expectations would be higher," said Tevi Troy, a former deputy HHS secretary in the Bush administration and the president of the American Health Policy Institute at the Hudson Institute. "That said, it will definitely be on the agenda."
Republicans argue that the public shares their opposition to Obamacare. The monthly Kaiser Family Foundation Health Tracking poll has found that the law is consistently viewed more unfavorably than favorably. A recent POLITICO-Harvard poll found that 54 percent of likely voters think the law is working poorly. And there is a sharp party divide: 94 percent of self-described Trump voters hold that view, while 79 percent of Clinton supporters believe the law is working well.
Yet there's a "careful what you wish for" dimension that injects political risk to repeal. The overall health law may be unpopular but many of its individual pieces — notably, banning insurers from denying coverage to people with preexisting conditions — score highly among voters of both parties. It's far from clear how the public would respond if the law is actually undone — and millions end up with no insurance, or at least none that they can afford. Trump's running mate, Gov. Mike Pence, has said there would be some kind of transition period for people who are now covered under Obamacare, but the campaign hasn't spelled out what that means.
It's not just the people who are getting covered who'd be affected. Rolling the health law back would create chaos in the health care sector — hospitals, insurers, doctors, some state governments — that have started to adjust to life under the ACA. That's not a small concern, given that health care is about one-fifth of the economy.
"If Trump wins, it is very likely that most health care stocks will sell off significantly," said Ipsita Smolinski, managing director of Capitol Street, referring to a sharp decline in stocks as a sign that investors are worried about the health sector's financial future. "Because he has pledged to repeal the ACA, it almost doesn't matter if he can do it or not."
A Trump administration could have a huge impact on the law even without Congress — or before Congress has time to act. The HHS secretary has significant discretion on major decisions that shape whether the law can function as intended. For instance, a Republican administration could relax requirements on Medicaid, or relax rules so states can set up alternatives to the ACA.
In Congress, there are hurdles to repealing the law. Full repeal of Obamacare is improbable because the Senate Republicans — though holding on to their majority — won't have the 60 votes to overcome a Democratic filibuster.
But if they can't scrap the whole thing, they do have a roadmap to repealing major parts of the law — probably enough to make it unworkable. They could use a complicated budget tool called reconciliation, which doesn't allow a filibuster. The repeal plan would have to go through elaborate review to make sure it complies with intricate budget rules and Democrats can challenge the results.
But the GOP did a dry run last year — and successfully got it through the House and Senate. There are expected to be enough Republicans in the Senate next year to make it feasible to do it again.
President Obama vetoed it last time. Presumably, a President Trump would not.
That reconciliation bill would have repealed the individual and employer mandates, the subsidies to help people buy insurance, the Medicaid expansion to cover low-income people and the taxes on medical devices and high-cost health plans. But even though it passed with strong support from Republicans, they knew at the time it wouldn't become law because Obama would veto it.
That dynamic creates skepticism among some conservatives now that it could pass again in 2017 when a president could actually sign it — and take away a health benefit from people.
"I think the Congress will end up being unable to pass that again if it were real. People who supported it would want to make sure their [constituents] are protected," said Jim Capretta, a resident fellow at the American Enterprise Institute, and a strong critic of the health law. "They won't be able to do that without thinking through what to do instead."
If the reconciliation effort were to pass, some pieces of the law would remain — creating the legislative equivalent of Swiss cheese. Insurers would still be legally required to accept anyone regardless of their health problems, and there would be no caps on coverage. The health plans have warned that leaving the costly requirements without mandating that people get covered would cause a death spiral, or essentially bankrupt them.
Many other questions will remain, and there is some debate among Republicans on how much of the law should be subjected to this process.
And despite the president-elect's talk of immediacy and "special sessions," it's unclear how quickly Congress could move, or how long a transition they'd establish before the coverage and subsidies go away.
"If we don't repeal and replace Obamacare, we will destroy American health care forever," Trump told the crowd at his rally last week. "It's one of the single most important reasons why we must win on Nov. 8."
Trump Can Kill Obamacare With Or Without Help From Congress
By Alison Kodjak National Public Radio November 9, 2016
President-elect Donald Trump has promised over and over in recent months that he will repeal and replace Obamacare when he reaches the White House.
"Obamacare is a disaster. You know it. We all know it," Trumpsaid at a debatelast month. "We have to repeal it, and replace it with something absolutely much less expensive."
Now that Trump will move into the Oval Office in January, the question is whether he'll be able to completely repeal the six-year-old law that has had an impact on every aspect of the U.S. health care system.
"It's a challenge for a Trump presidency," saysJack Hoadley, a research professor at Georgetown University's Health Policy Institute. "To get a true repeal and replace through, he needs 60 votes in the Senate." That's the minimum number of votes needed to block Senate action through filibuster.
"Repeal of the law is absolutely going to come up, and the only potential defense against that would be a Democratic filibuster — if Republicans even allow a filibuster," saysAustin Frakt, a health economist who runs the blogThe Incidental Economist.
But even if Trump can't repeal the Affordable Care Act in its entirety, there's a lot he can do through rule-making and smaller legislative changes to weaken the law and mold it more to his liking.
"They are probably, practically speaking, talking about leaving the ACA, as is, in place," Hoadley says. "Then he can change the ACA to have it showcase the kinds of plans he wants to see in place."
During his campaign, Trump proposed aseries of measuresthat he said will allow people to buy affordable health insurance policies outside of the Obamacare exchanges.
Those measures include promoting tax-free health savings accounts that might help individuals save money to pay for health care costs, and allowing people to deduct the cost of their premiums on their personal income tax returns. Trump has said he also wants to allow insurers tosell policies across state linesto boost competition.
Trump could alter the Obamacare exchanges to promote high deductible health plans and health savings accounts to get a result similar to what he's looking for.
"He could change the details of how the marketplaces work," Hoadley says. "It's all worked out through regulation. You could just suspend the regulations."
Alternatively, Trump could embrace thehealth care planpromoted by House Speaker Paul Ryan, which starts with repealing the Affordable Care Act. It includes many of the same principles as Trump's plan, but has more details.
One of the biggest challenges Trump faces is that aboutabout 20 millionpeople today have health coverage because of the Affordable Care Act, according to the Department of Health and Human Services. The uninsured rate hit anall-time lowof 8.9 percent this year, according to the Centers for Disease Control and Prevention.
An analysis of Trump's plan byThe Commonwealth Fundestimates it would increase the number of people who lack health insurance by as many as 25 million, and increase the federal budget by as much as $41 billion. That's because much of Trump's plan involves giving tax breaks to encourage people to buy insurance while taking away the requirement to buy insurance – a mandate embedded in Obamacare.
Even if Trump fails to repeal the law, Frakt says, he could easily destroy it from within by refusing to fund it through the budget process.
"The only thing stopping that is, it's a big deal to throw millions of people off insurance without offering something in return," Frakt says.
If Trump is right that his health savings accounts are a good enough replacement, then he'll be able to get rid of Obamacare through a vote or through neglect.