The ACA: Governing is much more difficult than campaigning

In the movie All About Eve, the Bette Davis character delivers a memorable line: “Fasten your seatbelts, it’s going to be a bumpy night.” As I’ve thought about how Republicans might go about delivering on their promise to repeal and replace the Affordable Care Act (ACA), this quote best sums up what to expect.

Despite the rhetoric that they will act quickly to repeal the ACA, Republicans cannot realistically expect Democrats to support repealing the ACA, at least not with the replace plans Republicans have articulated so far.

{mosads}While this means nothing in the House of Representatives, in the Senate where it takes 60 votes to pass controversial and/or complex legislation, which repeal is, this reality means something. Republicans only have a 52-48 majority meaning Democrats can deny Republicans an ACA repeal and replace through the normal legislative process.

Republicans could get around this by changing the rules through what is commonly called the nuclear option and lower the 60 vote threshold to a simple majority. But this would raise a host of other political troubles for Republicans (Newton’s Third Law) such as when they no control the Senate, which will occur, and then they will not have use of the filibuster.

Given this reality, the only other step available to Republicans is to use the reconciliation process. However, the reconciliation process is complicated, takes time and is limited and narrow in what can be included in a reconciliation bill. Generally speaking, it can only include matters that impact budget and taxes and it generally goes through regular order in Congress.

Normally, the House and Senate have to agree on and pass a single budget bill. It would contain instructions to relevant committees directing them to adopt legislation by a specific date and include one or more of the following general actions:

• Increases or decreases spending (outlays) by specified amounts over a specified time.
• Increases or decreases revenues by specified amounts over a specified time.
• Raises or lowers the public debt limit by a specified amount.

In practical terms this means only parts of the ACA that impact federal spending or taxes can be repealed by reconciliation. When Congress took this step last year with no expectation that the President would sign the bill, the bill included a repeal of the individual mandate, an end to the subsidies and an end to the Medicaid expansion (i.e., an end to federal funding leaving the cost up to the states).

The impact of such actions would cause chaos in the ACA marketplace as it would cast most of the 22 million covered lives out on the streets, so to speak.

Eighty-five percent of the people who bought insurance through the marketplaces have subsidized premiums with an average monthly cost of $75. Take away the subsidy and the vast majority of these individuals will no longer be able to afford their insurance policy, and would no longer have access to health care.

And with millions currently getting care — being treated for cancer, heart disease, having their diabetes controlled and other treatments — an abrupt end to subsidies could have grave consequences for the health of Americans.

For those on Medicaid, if the federal government ends funding for the Medicaid expansion that covers approximately 15-16 million citizens, it would be expected that states would in turn end the expansions, thus end health care access for this group.

It is hard to imagine that Republicans would take a step with such potential to harm the health of millions of Americans, but this is the debate going on among Republicans.

Calm heads seem to be prevailing as the discussion is now focusing on including a long transition date into the bill that would give Republicans time to agree on a replacement. Despite all the claims about a replacement plan, Republicans have no such plan. In fact, major differences in plans remain.

This new position parallels recent public opinion research from the Kaiser Family Foundation, which found that fewer Americans are in favor of repeal than before the election, and that a significant percentage of Americans are concerned about the negative impact repeal would have on those who have insurance through the ACA.

However, invoking Newton’s Third Law, a transition period could lead to instability and disruption in the marketplace.  Asking health insurers to remain in a program with an uncertain future is risky. In addition, there is much speculation that Donald Trump, upon being sworn in, may revoke the regulation that provides premium and copay support to low income persons with ACA coverage.

This would cause even more disruption and place a significant financial burden on insurers, hospitals and doctors and more importantly low-income individuals enrolled in the ACA. And again, asking insurers to shoulder an unplanned financial hit while at the same time waiting for perhaps up to two years to find out what the new law would look like is very risky.

And this analysis does not even touch the political challenges that any of these strategies creates. For both parties the politics are sensitive, complicated and tricky.

Newton’s Third Law, combined with the reality that governing is harder than campaigning, explains the bumpy nature of this political ride. Another great old quote captures our current situation. In 1942 Winston Churchill said, “Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”

William Pierce is a senior director at APCO Worldwide and was the former Deputy Assistant Secretary for Public Affairs at HHS from 2001-2005.

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