Republicans face divisions over ObamaCare repeal

Republicans face divisions over ObamaCare repeal
© Greg Nash

Congressional Republicans face internal divisions over how far to go in repealing and replacing ObamaCare, one of their top political priorities of the past six years, without disrupting the lives of millions of Americans. 

Conservatives like Sen. Ted CruzTed CruzFEC faults Cruz on Goldman Sachs loans in rare unanimous vote CBO score underlines GOP tensions on ObamaCare repeal Republicans go to battle over pre-existing conditions MORE (R-Texas) and Sen. Mike LeeMike LeeRepublicans go to battle over pre-existing conditions Senate gears up for fight on Trump's 0B Saudi Arabia arms sale Senate feels pressure for summer healthcare vote MORE (R-Utah) are pushing for the law to be ripped out “root and branch,” something Senate Majority Leader Mitch McConnellMitch McConnellOvernight Energy: Trump energy nominees face Congress | OPEC to extend production cuts Senate confirms Trump's first lower-court nominee Top GOP senators tell Trump to ditch Paris climate deal MORE (R-Ky.) has promised to do.  

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One Senate Republican aide said the far-reaching repeal measure passed by the Senate in 2015 should be the “baseline” for unwinding the law.  

“I wouldn’t expect anything less than that, and of course people will be pushing for more,” the aide said. 

But centrist Republicans are worried about millions of people being kicked off insurance rolls if ObamaCare is repealed. They’re hoping to reach compromises with Democrats in hopes of transitioning as smoothly as possible away from the law. 

Sen. Shelley Moore CapitoShelley Moore CapitoCongress should act on measure to help Medicare, small businesses Taking the easy layup: Why brain cancer patients depend on it Republicans give Trump's budget the cold shoulder MORE (R-W.Va.) told The Hill last year that she was “very concerned” about the 160,000 people who were then receiving health insurance in her state through the law’s Medicaid expansion. 

Similarly, Sen. Roger WickerRoger WickerIndustry pushes lawmakers to build 355-ship Navy GOP senators on Comey firing: Where they stand United Airlines grilled at Senate hearing MORE (R), whose home state of Mississippi has the highest poverty rate in the nation, said he’s worried about hurting people who received insurance for the first time. He hopes to work with Democrats to find a replacement program to limit the chances of a major disruption. 

“We’ll see if we can reach some sort of consensus with our Democrat friends on how to make this repeal and replace. Clearly we don’t want to do any harm to people who are in the system now. We want to be mindful of that,” Wicker told reporters Wednesday. 

But the ObamaCare repeal package Congress passed last year, which President Obama vetoed, would have rescinded the federal government’s authority to run health insurance exchanges and eliminated the subsides designed to help people afford plans in those marketplaces. Not a single Democrat in the Senate voted for it, and only one Democrat in the House did. 

President-elect Donald TrumpDonald TrumpRaw deal: Compassionate conservatism, Donald Trump style Democrats likely to keep losing if they fail to do more than 'resist' Cohn explains Trump jab at Germany MORE indicated in an interview with The Wall Street Journal Friday that he is open to keeping some parts of ObamaCare. 

Trump said he supports keeping in place the prohibition on insurance companies discriminating against people with pre-existing conditions and the provision allowing young adults to stay on their parents’ health insurance plans until age 26. 

“I like those very much,” he told the Journal.

Trump said he changed his view on the need for an across-the-board repeal after meeting for 90 minutes with Obama at the White House Thursday.

“Either ObamaCare will be amended, or repealed and replaced,” Trump said, opening the door to two routes for addressing ObamaCare on Capitol Hill.

Republican aides on Friday said the next steps on ObamaCare would be discussed next week when lawmakers return to Washington to hold leadership elections. 

Healthcare experts say that keeping the ban on discriminating against pre-existing conditions would likely require keeping some of ObamaCare’s subsidies in place. The subsidies were designed to expand insurance pools and make it economically viable for insurance companies to sign up patients with costly chronic health problems. 

Douglas Holtz-Eakin, who served as chief economist to the Council of Economic Advisers and as director of the Congressional Budget Office under President George H.W. Bush, said all the Republican plans to replace ObamaCare that he’s reviewed include some sort of subsidy.  

“It’s essentially fait accompli that there will be some sort of subsidy,” he said. 

People who earn up to 400 percent of the federal poverty level earn premium subsidies under ObamaCare — about 9.4 million people, according to the Centers for Medicare and Medicaid Services (CMS).

Thomas Scully, who served as CMS administrator from 2001 to 2004 under President George W. Bush, said Republicans might scale the subsidy down to only apply to people earning 250 to 350 percent of the federal poverty level. 

“My guess is they’re not going to want to leave 15 million or 20 million people in the streets right off the bat. They’re going to want to say we’re repealing it but we have to take it down to replace it constructively,” he said.    

“My guess is they’ll scale back the scope of the benefits significantly and probably scale back the entitlement significantly and significantly loosen the regulatory oversight and come back with something that covers a lot of people with a skimpier benefit for fewer people in the upper middle class,” he added.

Scully predicts Republicans will pass legislation repealing ObamaCare soon after Trump takes the oath of office in January but delay the implementation of the repeal until 2018 or even 2019 to give them time to come up with replacement reforms. 

“Are you really going to take insurance away from this many people and leave them with only a tax credit? I think there’s a powerful argument that they won’t do that,” said Thomas Bulleit, a partner specializing in healthcare policy at the law firm of Ropes & Gray. 

The other big question facing Republicans is what to do about the Medicaid expansion, which was adopted by 31 states, including Ohio, Michigan and Pennsylvania, three Rust Belt states that helped push Trump to victory on Election Day.  

Kentucky, McConnell’s home state, also expanded Medicaid under ObamaCare. At the beginning of last year, nearly 500,000 people in Kentucky had gained coverage under Medicaid or the Children’s Health Insurance Program because of the healthcare law, according to the Department of Health and Human Services.

Republican healthcare experts say it’s unlikely that Congress will reverse the Medicaid expansion in these states. More likely, lawmakers will enact reforms to curb its costs and give states flexibility to administer smaller payments from Washington. 

Repealing the Medicaid expansion was a sticking point within the Senate Republican Conference last year. McConnell addressed the concerns of colleagues such as Capito by proposing to phase in the repeal of the Medicaid expansion over two years to give the federal government and states time to figure out how to replace it.

Holtz-Eakin said what Republicans would do about the Medicaid expansion “is the hardest to know and one of the tougher calls for them.”

He said the Obama administration and the Democratic-controlled Congress in 2010 expanded Medicaid without reforming it. At the very least, he said, Republicans will push for significant changes to the program. 

“Whatever they do, it’s not going to replicate writing a big check into a program that needs to be fixed, but where they go, I don’t know,” he said.