The All-But Inevitable Attack on Obamacare

On a sunny day in June 2015, President Barack Obama delivered remarks in the White House Rose Garden celebrating a landmark Supreme Court win for his signature health care law, the Affordable Care Act.

The law, Obama said, was now "woven into the fabric of America" after the justices' opinion in King v. Burwell upheld a major provision in Obamacare that appeared to cement the standing of the law.

"After more than 50 votes in Congress to repeal or weaken this law, after a presidential election based in part on preserving or repealing this law, after multiple challenges to this law before the Supreme Court, the Affordable Care Act is here to stay," he said.

But Tuesday's surprise victory for Republican Donald Trump, suggests a different fate for Obamacare.

By also keeping control over the House and Senate, Republicans are likely to follow through on their plans to "repeal and replace" one of the president's signature achievements. Trump has blasted the Affordable Care Act in recent weeks, and his campaign website says that "on Day One" of his administration he will ask Congress to "immediately deliver a full repeal of Obamacare."

Though Trump did not mention the Affordable Care Act in his victory speech Wednesday, Republican leaders immediately referenced their plans to pounce on the law.

Senate Majority Leader Mitch McConnell of Kentucky said Wednesday that Republicans would move quickly to roll back the Affordable Care Act, saying it was "high on our agenda."

Repeal could take several forms but will most likely be tried through a reconciliation bill, a spending-related measure that requires only a simple majority of votes in the Senate. Such a move is preferred because 60 votes are typically required to pass most legislation in the upper chamber and the GOP currently controls 51 seats, with one race to be decided in a runoff election next month. If passed, certain portions of the law would gradually phase out.

Congress sent such a bill to Obama earlier this year that would have pulled apart Obamacare's expansion of Medicaid and funding to help subsidize poorer people's purchase of private health insurance. The bill allowed for a two-year transitional period for the cuts to take effect and would have also repealed the "individual mandate," one of the most controversial elements of the law, which requires people to buy health insurance or play a penalty.

Obama vetoed the bill, but Republicans under Trump could try a similar measure.

"This Congress, this House majority, this Senate majority, has already demonstrated and proven we're able to pass that legislation and put it on a president's desk," House Speaker Paul Ryan of Wisconsin said in a press conference Wednesday.

Republicans also could have a better shot at implementing some of their health care reform proposals, which include allowing health insurance companies to sell plans across state lines and promoting health savings accounts.

Gov. Mike Pence, now the vice president-elect, said last week the Trump plan also would allow for Medicaid funds to be distributed through block grants – a proposal that would increase state control of the program but potentially limit the amount of federal aid provided.

Diane Rowland, executive vice president at the Kaiser Family Foundation, notes, however, that such grants can be limiting in various emergencies, pointing to budget issues in states as well as drug-price hikes and the opioid epidemic. The system is currently set up to have the federal government match state needs.

"The incentive is to give state more flexibility over who they cover and what services they cover in return for a ceiling on what they spend," she says. "A block grant really puts more pressure on state budgets."

Full repeal will be difficult, given that Democrats will halt votes in the Senate. Tim Jost, emeritus professor of law at Washington and Lee University, noted this in a blog post on Health Affairs Wednesday.

"The ACA is inextricably interwoven into our health care system and is not going away immediately," he wrote.

And repeal is likely to be met with backlash from constituents, given that Congressional Budget Office estimates suggest 22 million people could lose coverage. The law is credited with driving the number of uninsured to a historic low.

"Republicans have consistently advocated repeal of the ACA. But the disruption of taking insurance from 20 million people may give pause," tweeted Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation.

Prior to the passage of the Affordable Care Act, both parties were struggling to find ways to combat climbing medical costs – an issue that will still need to be addressed by Republicans if Obamacare is gutted. Costs for medical care continued to rise after the law was implemented, though millions were able to access coverage for the first time. While some people faced increasing costs, certain provisions of the law have proved popular among voters, including barring health insurance companies from discriminating against patients who have pre-existing conditions and allowing children to remain on a parent's plan until the age of 26.

Reformers may look at other areas to change. Joseph Antos, the Wilson H. Taylor Scholar in Health Care and Retirement Policy at the conservative American Enterprise Institute, notes that some alterations to the exchanges may occur and that the structure of plans may change to allow consumers to buy health plans that cover fewer medical services than what Obamacare plans currently mandate.

"You can't just repeal the law because then the headline will be, 'Trump throws out insurance for tens of thousands without recourse," he says.

It's unclear whether industry groups will be supportive. America's Health Insurance Plan released a statement Wednesday saying all Americans deserve access to affordable health coverage.

"A competitive private market can deliver more choice, higher quality and lower costs," Kristine Grow, a spokeswoman for the group, said in an email. "We will work across the aisle – with every policymaker and the new administration – to find solutions that deliver affordable coverage and high-quality care for everyone."

In championing repeal efforts, Republicans note that voter dissatisfaction about the law is high. The fourth open enrollment period opened to grim headlines about double-digit rate hikes and limited coverage options on the exchanges. Without passing any laws, a Trump administration could decline to engage in the same outreach efforts as the Obama administration, not aggressively encouraging people to sign up for tax-subsidized private insurance through the exchanges. This could cause even more insurers to pull out of the exchanges during subsequent open enrollment periods, possibly leaving some counties without any subsidized insurance options and driving up prices in other areas.

They'll meet opposition. Ron Pollack, executive director for the nonprofit Families USA, which helps people use the exchanges, said in a statement that his group would be on a "total war footing to protect health coverage for millions across America" and warned that repeal would have "tragic consequences." He vowed his group would fight at the grass-roots level and in Congress.

Enroll America, a group that also helped with exchange sign-ups, released a statement Wednesday encouraging people to continue applying for exchange plans. Anne Filipic, the group's president, noted that anyone who buys coverage before Dec. 15 will have coverage that begins Jan. 1.

"We know that consumers have questions about the election and the implications for their coverage moving forward. … Right now, it is critically important to reassure consumers that nothing has changed," she said.