Why So Hard to Kill the Affordable Care Act?
GOP consensus on swift repeal proves disastrously brittle
by Shannon Firth | April 06, 2017 | Washington Correspondent, MedPage Today
WASHINGTON -- For years, Republicans vowed that if they ever got control of the White House and both houses of Congress, the Affordable Care Act would quickly end up in the trash heap. As of January 20, those pieces were firmly in place.
Yet nearly 3 months later, the GOP appears no closer to enacting a repeal-and-replace bill than they were when Barack Obama was sitting in the Oval Office.
House Republican leaders have been unable to forge a consensus among its conservative and moderate wings as to what should come after the ACA. One bill had to be pulled from a floor vote when it became clear that neither the GOP's Freedom Caucus nor Democrats would support it. And, earlier this week, a push led by top administration officials to appease the Republican conservatives -- by making certain ACA elements retained in the GOP plan optional for states -- was quickly declared dead on arrival.
MedPage Today asked physicians and policy experts why President Obama’s signature legislation is so hard to kill and whether Republicans might give up trying.
“Advocacy against the AHCA [American Health Care Act, the GOP’s initial repeal-and-replace bill] was broad and intense, with health care and public health organizations repeatedly raising concerns about health insurance coverage, access, and costs, including proposed dramatic changes to Medicaid funding that would preferentially hurt low-income people (including children), and risks of coverage gaps for those with chronic and pre-existing conditions,” wrote Jan Carney, MD, MPH, associate dean for public health and professor of medicine at the University of Vermont in Burlington, Vt., in an email.
Carney underscored the importance of the Congressional Budget Office's report projecting a dramatic increase in the number of uninsured Americans -- 14 million more in 2018 and 24 million more in 2026.
She also highlighted an April 4 Kaiser Family Foundation poll, which found 75% of Americans felt that Congress should work on fixing the ACA instead of repealing it.
Also, noted Jennifer Tolbert, director of state health reform for the Kaiser Family Foundation, a left-leaning think tank, “The ACA is a comprehensive law with lots of moving parts and pieces that fit together.” By choosing to use the budget reconciliation process to repeal the law Republicans tied their own hands in terms of the changes they can make, she added in a phone interview. (A budget reconciliation bill is limited to provisions that relate to spending, other language can ultimately be blocked by the Senate parliamentarian.)
The fragmented Republican party and the AHCA's Medicaid provisions combined made it difficult for the GOP caucus to reach a compromise, said Daniel Blumenthal, MD, MBA, chief fellow in the Division of Cardiology at Massachusetts General Hospital in Boston. Republicans in states that expanded Medicaid were given replacement funds to cope with a roll-back of expansion -- and the potential backlash from beneficiaries -- which Republicans in non-expansion states viewed as unfair. Then the Freedom Caucus wanted to scrap the Medicaid expansion entirely, he said.
“Ultimately they were unable to agree on the number of people whose health insurance should be terminated,” Blumenthal added.
The basic problem is that “Republican moderates believe the ACA should be replaced but they want to ensure that those who have gained coverage through the ACA do not lose it,” said Tim Callaghan, PhD, assistant professor, Texas A&M School of Public Health, whereas “conservative Freedom Caucus members are more concerned with limiting regulation and government involvement in health then maintaining coverage.”
Said Daniel Ehlke, PhD, of SUNY Downstate Medical Center in Brooklyn, N.Y., “As long as this basic calculus remains unchanged, it’s going to be very difficult to work out a deal.”
Asked whether Republicans will continue their attacks on Obamacare, Ehlke noted that, having promised a repeal for so long, the GOP will find it “politically difficult to walk away entirely” from the effort.
“The administration could unilaterally do a lot of damage to the ACA by simply refusing to continue [certain financial subsidies],” he said, referring to a pending court case the House began against the Obama administration that questioned their legality, which the administration will be forced to act on soon.
Ehlke said a comprehensive repeal and replace seems less realistic at the moment, but Republicans may attempt to implement portions of the AHCA such as the Medicaid redesign -- shifting the entitlement program to a per-capita cap block grant.
“It seems like they are really losing steam, and risking precious political capital on health reform, without a clear consensus or compass for where they want to go,” added Daniel Derksen, MD, director of the University of Arizona Center for Rural Health.
Asked whether the latest effort at compromise giving states an additional $15 billion -- an proposed by two Freedom Caucus members Thursday -- to help them pay for sicker patients would resuscitate the bill, Derksen didn’t think so.
“As a practical matter, funding high risk pools, or variants of that strategy – don’t have great track records of success.... I don’t think this will entice entrenched extremists who wish to do away with public subsidies of health insurance and coverage entirely.”
But other experts remain confident that Republicans will still work out a repeal-and-replace deal.
In a phone call, Charles Sauer, a legislative fellow at the Goodman Institute, a conservative think tank, said Congress is “a few weeks away” from an agreement.
As to the pressure to act before the end of April, the deadline for setting a new budget, Sauer professed unconcern. "We've gone years without a budget before... You can do repeal anytime."
“There will be a next round,” predicted Jay Wolfson, DrPH, JD, of the University of South Florida. But, he argued, if negotiations continue to take place “in back anterooms of the legislature where rules are bent to produce the illusion of substantive legislation, the next round will fail as well.”