What a Republican Senate Means for Obamacare—and What It Doesn't

The new Republican majority will likely be able to score some policy changes and force difficult votes as 2016 approaches.

Republicans won a Senate majority in part by pledging to repeal Obamacare. Now they have to figure out what to do instead.

Mitch McConnell, soon to be the Senate majority leader, has to strike a somewhat delicate balance on the 2010 health care law: satisfy the conservative base, as well as senators who campaigned on repeal, without appearing to use the GOP's total control of Congress solely to throw stones at the past.

His critics on both sides will make life difficult: Some conservatives still won't accept anything short of the impossible, but the GOP won't be well positioned for 2016 if it can't convince voters that it is more than the anti-Obamacare party. Still, a plan to strike that balance is already taking shape.

The first part of the plan is a symbolic effort for full repeal, and a push that—many GOP operatives expect—McConnell and company will push forward as far as possible.

Because Republicans lack the 60 seats needed to beat a Democratic filibuster, McConnell can't force a vote on a simple, straightforward repeal bill. But he has said several times he would use the budget reconciliation process, which only requires 51 votes, to pass anti-Obamacare measures. Reconciliation probably can't be used to pass a clean, repeal-it-all proposal—and Obama would veto it if it did—but by pushing the measure, Republicans incumbents inoculate themselves against charges that they let the party's least-favorite law stand, as well as fulfill campaign promises.

McConnell himself campaigned on repealing Obamacare "root and branch," and several of his caucus' newest members made similar promises: Joni Ernst, the senator-elect from Iowa, said repealing Obamacare would be her first priority in the Senate. And conservative power players like Sen. Ted Cruz won't be satisfied with anything less than the biggest swing for the fences (if that).

After the repeal fervor fades, however, Senate Republicans are likely to turn to measures that have some hope of passage, including targeted attacks on unpopular parts of the Affordable Care Act.

The main targets will fall into two categories: things Obama might actually sign, and bills that will never become law but might help force a political issue that's difficult for Democrats.

Obamacare's tax on medical devices is considered low-hanging fruit. Device-tax repeal could have passed the Senate with bipartisan support even before Tuesday's elections, had it come up for a vote, and it could definitely pass under a GOP majority. Because it wouldn't strike at the heart of the law, Obama might even sign it.

Revenues, including the device tax, will be easier targets than policies that sit closer to the core of the law's coverage expansion. Republican aides have also mentioned the law's tax on insurance policies as a possible target for piecemeal repeal.

Then there are the purely political votes. Republican aides have said, for example, that Obama will almost surely be forced to veto a bill repealing the health care law's individual mandate. There's no question he would do so -- the law wouldn't function without it. But simply holding the vote, especially closer to 2016, would put Democratic incumbents in a tough spot and put a deeply unpopular part of Obamacare back in the spotlight.

Somewhere between real policy changes and pure politics are issues like the law's employer mandate. The White House has already delayed the mandate twice and agreed to repeal certain reporting requirements for small businesses, so changes to the policy—such as redefining a "full-time" employee—might be possible.

Outright repeal of the employer requirements, on the other hand, would probably attract support from moderate Senate Democrats but not the White House, allowing the GOP to argue that it's pursuing bipartisan ideas while Obama stands in the way.

Republicans are also likely to target the Independent Payment Advisory Board, or IPAB, a controversial cost-cutting panel tasked with slowing the growth of Medicare spending. Obama hasn't nominated anyone to the 15-member board yet, and unless he does so in a lame-duck session, the IPAB won't have any members for the duration of his presidency.

Even some Democrats weren't wild about the IPAB to begin with, and a slew of health care lobbying groups want to see the panel officially disbanded before it has a chance to cut their Medicare payments.

Overall, this strategy—start with a big repeal vote and then move on to smaller components—is probably McConnell's best chance to make everyone happy, or at least keep anyone from being too deeply unhappy.

In an interview with the Washington Post this past weekend, Cruz said a Republican majority should "pursue every means possible to repeal Obamacare," and if that fails, move on to address specific provisions "one at a time."

Sen. Rand Paul, another likely presidential contender in 2016, isn't as worked up about repeal as Cruz, but said a vote on repeal is fine. "I'm not saying we don't have a vote on repealing Obamacare; we should have a vote. I'm not sure how far that goes but we should have a vote on it. But I also want to pass some stuff," he said at a campaign rally, according to BuzzFeed.

What you won't see from a GOP majority, however, is a push to tout a health care reform bill of their own. Though some conservatives activists want the party to launch their own comprehensive bill, the political calculus makes that extremely unlikely. All health care policies have trade-offs, including ones that are difficult to stomach: more coverage means higher premiums, lower premiums mean higher out-of-pocket costs, and so on.

That's a minefield Republicans have no interest in navigating two years ahead of presidential election—especially given that they still lack the power to repeal Obamacare.