Where Does Obamacare Go From Here? 3 Scenarios for Health Care Reform
Policy + Politics

Where Does Obamacare Go From Here? 3 Scenarios for Health Care Reform

Joshua Roberts

The corpse of the Republican Senate’s Affordable Care Act repeal effort wasn’t even cold before the reanimation effort began on Friday morning. Just hours after what looked like a last ditch bid by the GOP to get something done went down to defeat in a 51-49 vote that featured three Republican defections, members of the House of Representatives were claiming that the GOP’s goal for the past seven years -- elimination of President Obama’s signature domestic policy accomplishment -- was still in reach.

“We should not give up,” House Speaker Paul Ryan said on Friday morning, though he admitted to being “frustrated” by the Senate’s failure to pass a bill that might have allowed it to move into a conference committee with the House, which passed its own legislation earlier this year.

Related: The Health Care Fight Isn't Over, Despite Democratic Cheering

But Ryan was subdued compared to North Carolina Rep. Mark Meadows, the chairman of the conservative Freedom Caucus, who promised that a new health care bill is on the way -- one that he believes at least 50 senators will be willing to support.

“We continue to work on two different plans with our Senate colleagues,” Meadows said in an interview with The Washington Examiner.

“I believe we deliver, still, on healthcare," Meadows told the Examiner. “To suggest that everything is over is not understanding the dynamics going on right now in the Senate. It's not over.”

Meadows certainty seemed at odds with the gloomy assessment that Senate Majority Leader Mitch McConnell offered on the floor in the early hours of Friday morning, after the dramatic vote.

“This is clearly a disappointing moment,” he said. “I regret that our efforts were not enough, this time.”

He added, “It’s time to move on.”

Related: What a Waste—Senate Health Care Debate Squanders Time and Millions for Nothing

But moving on apparently means different things to different lawmakers under the circumstances -- not to mention what it means to a President Trump who appears to be angry that one of his major policy promises has been in limbo since he took office in January.

There are, at this point, several paths available to Republicans and the White House.

1. Try, Try Again

Just because everyone thought the failure last night of the so-called “skinny repeal” of the ACA was the Senate’s final effort doesn’t mean it really is.

Meadows point, and it is a valid one, is that there are at least two more versions of a Senate repeal plan that have not been given consideration by the upper chamber yet, both of which have reportedly been sent to the Congressional Budget Office for scoring. That will help lawmakers understand whether or not they fit into the relatively narrow constraints of the Senate budget reconciliation process.

One is a proposal from Texas Sen. Ted Cruz that is similar to the Better Care Reconciliation Act, a measure that has already failed before the Senate, but with some crucial differences. The Cruz amendment’s key provision is that it would allow insurers to offer policies that do not comply with various requirements imposed by the ACA, so long as they also offer plans that do comply.

Related: Hefty Price Increases Have Stabilized the Obamacare Insurance Market

The Cruz plan would not constitute a full repeal of the ACA. However, like the BCRA, it would eliminate government mandates. Government subsidies for premiums would still be in place, but the proposal appeals to some conservatives because it offers insurers a way around many of the restrictions they currently operate under. It would also likely lower premiums, on average, although that would be largely a factor of plans offering dramatically less coverage.

A second plan is radically different from all of the others that have been proposed so far. South Carolina Sen. Lindsey Graham and Louisiana Sen. Bill Cassidy have proposed a plan that would effectively punt most of the hard decisions about how to reform health care to the states.

The Graham-Cassidy bill would turn most federal spending on health care into block grants, money that would be passed on to the states with limited restrictions, allowing them to retain the general ACA system if they prefer, or to construct their own system, funded in large part by federal dollars.

2. Burn It All Down

In this scenario, President Trump makes good on his threats and wages all-out war to bring the operation of the Affordable Care Act to its knees. It would be an act of retribution that he thinks would bring the Democrats to the bargaining table and result in enactment of legislation close to what the Republicans have been seeking all along.

After the disastrous early morning vote, Trump tweeted that he would “let ObamaCare implode, then deal.”

There is no question that Trump has the administrative power to accelerate the decline of Obamacare if that’s what he ultimately decides to do.

Related: Can Democrats Out-Populist Trump?

For instance, he could direct the Internal Revenue Service to curtail enforcement of the individual mandate, which is at the core of the subsidized health insurance program. He could also order his administration to cease providing millions of dollars in cost-sharing subsidies to insurance companies that helps reduce co-payments and other out of pocket costs for low and moderate-income Americans.

Senate Minority Leader Chuck Schumer (D-NY) said Friday that Trump’s plans to “sabotage” the ACA would hurt millions of innocent Americans and hurt Trump and the Republicans politically down the road. If Trump does indeed make good on his threat, congressional Republicans will have to decide whether to aid and abet the president or go their own way.

3. Make Up and Play Nice

The Republicans clearly hold the whip hand on Capitol Hill, and will have much to say on whether the GOP continues to exclude the Democrats from important decision making or begin to bring them into the fold. Sen. Lamar Alexander (R-TN), the chair of the Senate Health, Education, Labor and Pensions Committee, and other senior Republicans plan hearings in the coming weeks to begin a process of regular order to seek compromises on fixing Obamacare.

The dramatic floor speech earlier this week by Sen. John McCain (R-AZ) -- pleading for bipartisanship and a return to “regular order” shortly after learning that he was suffering from an aggressive form of brain cancer – might result in a softening of the Republicans’ rhetoric and a willingness to consider a different pathway.

After watching the last of his proposals for repealing portions of the ACA go down in flames early this morning, a somber Mitch McConnell looked across the Senate floor at the Democrats and said “So now I think it’s appropriate to ask what are their ideas.”

Schumer for months has said that he and other Democrats were eager to negotiate with Trump and the Republicans over compromise language to fix Obamacare, but only if the Republicans abandon their efforts to destroy the 2010 health insurance legislation and replace it with a Republican alternative.

On Friday, Schumer renewed his call for negotiations and outlined several possible areas of agreement. Those include measures to make permanent the cost-sharing subsidy for insurers; further protect insurers against excessive losses through a “reinsurance” program; and addressing the plight of some rural counties that that currently lack coverage.

“Nobody has said Obamacare is perfect, nobody has said our health care system doesn’t need fixing,” Schumer told reporters. “The problem was when they [the Republicans] tried to just pull the rug out from under the existing health care system. So change it, improve it, but don’t just take a knife and try to destroy it and put nothing in its place.”