ACA repeal could start in January, liberal group warns it would ‘unravel’ market

Republicans in Congress are aiming to start eliminating aspects of the Affordable Care Act (ACA) and its regulations on “Day 1” of President-elect Donald Trump’s administration.

According to a memo from the Senate Republican Policy Committee, party members “will keep that promise” to repeal and replace the ACA. The most immediate steps will come through Trump-appointed leaders at HHS and other agencies.  

“The original health care law itself was 2,700 pages, but there were also more than 40,000 pages of administrative rules, regulatory guidance, and even blog posts setting Obamacare policy,” the memo said. “A lot of this can be scaled back on day one. Phrases giving authority to the secretary of HHS—such as ‘Secretary shall,’ ‘Secretary may,’ ‘Secretary determines,’ ‘Secretary must,’ ‘Secretary will,’ and ‘by the secretary’—appear at least 1,853 times in the law.”

The rest of memo went over a possible strategy for repeal. Using a process called budget reconciliation, Congress could void large parts of the ACA that related to the federal budget while only needing a simple majority to pass the Senate, rather than the 60 votes necessary to avoid a filibuster.

This route was tested in 2015 when the Republican-controlled House and Senate passed a budget reconciliation which, among other provisions, voided the ACA’s individual and employer mandates by eliminating the tax penalties for not buying or providing insurance and prohibited HHS from collecting or distributing funds in the law’s reinsurance program.

It also repealed the law’s tax credits and subsidies for buying coverage, as well as rolled back the federal matching funds for states expanding Medicaid, but only after a two-year delay. If a similar delay was used in early 2017, those major changes wouldn’t be implemented until after the next elections in the House and Senate.

The 2015 budget reconciliation bill was vetoed by President Barack Obama, as expected, but with Trump’s surprise victory, a repeal appears all but guaranteed.

Health policy groups, particularly liberal-leaning ones, warned the Republicans’ plans would have major and immediate consequences.

The liberal-minded Center for American Progress (CAP) said it was a “fallacy” that delaying key provisions of the repeal plan would ensure a smooth transition away from the ACA. CAP’s health policy vice president, Topher Spiro, along with research associate Thomas Huelskoetter, wrote it would instead result in the “complete unraveling” of the individual insurance market by the end of 2017.

“If there is not certainty before then about the state of the marketplaces in 2018, then few—if any—insurers would be willing to offer coverage in 2018 since their participation would carry the risk of significant financial losses for the year,” they wrote. “And if a reconciliation repeal bill does pass and it becomes clear that the marketplaces soon will no longer exist, then healthier consumers would be less likely to enroll or re-enroll in coverage, leaving the marketplace with a less healthy, more expensive risk pool. Knowing this, many insurers would cut their losses and exit the marketplace after 2017.”

Other policy groups, like the Commonwealth Fund, have said the result of the Republican healthcare proposals would be taking away insurance from nearly 20 million people. Some lawmakers dismissed that argument to POLITICO.

“People have crappy insurance now,” said U.S. Rep. John Shimkus, R-Illinois. “They have high costs, they have high deductibles, it’s like they don’t have insurance. So this fear that they’re going to lose something that they don’t think they have anyway is crazy.”

Democrats are preparing to defend the law, with several lawmakers pointing out Republicans don’t have a full replacement plan, but rather a 37-page white paper with no cost analysis released earlier this year.

Until actual legislation is filed, Democrats may focus on promoting the law’s benefits.

 “Notwithstanding people’s concerns about premium announcements, this is still a law that’s insuring 20 million people with 80 percent satisfaction rates. That’s pretty stunning success rate for the Affordable Care Act,” U.S. Sen. Chris Murphy, D-Connecticut, said to The Hill.