Via NEJM, an opinion piece: The End of Obamacare. Excerpt:
The GOP-led House has already voted to repeal Obamacare dozens of times and will most likely do so again. The situation in the Senate is more complicated. The Republican majority of 51 senators is far less than the 60 votes necessary to overcome a filibuster and thereby pass contested legislation. However, the GOP can use a legislative procedure that requires only a simple majority — budget reconciliation — to overturn Obamacare’s main coverage provisions.
Republicans face challenges in dismantling the ACA. Procedural limits mean that reconciliation can be used to repeal many Obamacare provisions but not the entire law (its insurance market regulations would probably be spared). Moreover, some of its provisions, such as banning insurers from discriminating against people with preexisting conditions and allowing children to stay on their parents’ health plan until 26 years of age, are popular.
The GOP could attempt to retain such reforms, which President-elect Trump has expressed interest in maintaining, while eliminating the mandates for individuals to obtain and larger employers to offer insurance coverage or pay penalties, the Cadillac tax on high-cost private plans, and other measures the GOP opposes. Many ACA policies, though, are interconnected: without a requirement that individuals either obtain insurance or pay a penalty, regulations prohibiting insurers from excluding sicker people from coverage or charging them higher premiums are not viable. Picking and choosing to keep only the ACA’s popular provisions is easier said than done.
Furthermore, more than 20 million Americans have gained insurance coverage since the ACA’s enactment, representing a sizable constituency of beneficiaries of Medicaid expansion and subsidized marketplace insurance. Repealing those benefits without adequate replacements would de-insure a substantial share of the U.S. electorate, inviting a political firestorm.
Therein lies the GOP’s chief quandary: talking about repealing the ACA is much easier than actually repealing and replacing it. The GOP could reintroduce a repeal bill, vetoed by Obama, that congressional Republicans passed in 2015 (through budget reconciliation in the Senate) stripping the ACA’s core coverage provisions away.
But with what, if anything, will the GOP replace Obamacare? Trump’s health care platform comprises a handful of bullet points — including allowing the interstate sale of health insurance, expanding the use of health savings accounts, and establishing high-risk pools.
None of those policies would do anything meaningful to restore the access to health insurance that repealing the ACA would take away from millions of Americans. Trump’s reform vision remains largely a mystery.