It was a “day one” goal for the Trump administration to repeal Obamacare. Vice President Mike Pence said in early January that the “first order of business” was to repeal and replace Obamacare, and President Trump backed up his urgency with a storm of tweets urging Congress to act. House Speaker Paul Ryan said work on Obamacare was a “first priority” for the first session of Congress under Trump.
But does anyone know approximate timeline of when a repeal might happen or what the Republican plan will entail? In an interview with Fox News’s Bill O’Reilly Sunday, Trump indicated that maybe the “process” of an Obamacare repeal might drag into next year, although Ryan later said that the legislation would be done this year. The uncertainty around repeal was the central subject of a a televised CNN debate on Tuesday night between Senators Ted Cruz and Bernie Sanders, where moderators and audience members asked Cruz the question early: What do Republicans have planned?
Cruz essentially admitted that the answer is still uncertain, declining to even mention a specific timeline, though he did say that there is “an urgency to honor the promises we made ... Should Congress move quickly to repeal Obamacare? Absolutely.” He spent much of his time attacking Obamacare and buying time for a repeal effort instead of providing specifics for what repeal might entail and the process for implementing it.
Those comments from Cruz were the latest in a long line of delays and shifts in Republican rhetoric on repeal. “Day one” became week two and week three, and then—maybe—February 20. The “first priority” turned into the “first 100 days.” “Swift” became “careful,” sometimes “essentially simultaneously”—provided Representative Tom Price is confirmed as Health Secretary. Somewhere along the line talks of a full repeal became murmurs of “repair.”
Members of Congress have held several contentious town hall meetings about the repeal with constituents, a development that has Republicans scrambling to figure out how to control and limit protests. Secret audio from a Republican retreat in January found Republicans fretting about the consequences of a repeal, and Senator Bob Corker was pointed Tuesday in his assertion that “there’s not any real discussion taking place right now.”
The number of alternatives has ballooned, a development that should not inspire confidence in the party’s ability to move quickly. Although, as Cruz noted, many of the plans in circulation agree on the broad strokes of repealing the ACA’s subsidies for purchasing private insurance and Medicaid expansion, there are significant differences in the details, and even the consensus over broad strokes has broken down over the past few weeks.
The reconciliation bill designed to defund Obamacare can only achieve those spending reductions. The plans favored by Price and Ryan are considered the core orthodoxy in their replacement of public insurance with tax credits and health spending accounts, but differ dramatically in the spending they allocate, the pieces of Obamacare that they roll back, and in some of the mechanisms of caring for high-risk people. A plan from the House Republican Study Committee uses tax deductions instead of tax credits. A newer plan from Senator Bill Cassidy and a group of three other Republican senators in health leadership eschewed the orthodoxy entirely with a plan that repeals the ACA’s mandates but allows states to choose to keep localized versions of the health reform with federal funding.
But the reason no plan has emerged—not least in any “swift” time frame—has been that each of those Republican plans might wind up with millions more uninsured, and millions more angry voters and town hall meetings. In the debate, Sanders quickly seized on those flaws. “The truth is that the Republicans are now in a panic,” he answered, “because Americans have caught on that the absolute repeal of Obamacare without improvements to make it better would be a complete disaster.”
Sanders is right. The task of trying to find a solution that meets the core promises of repealing Obamacare while also not destroying health-care markets and not simply stripping coverage from people has been an incredible strain on the Republican Party. Although Sanders is a proponent of single-payer universal health-care, he often stressed the point that the current law’s ban on insurance plans excluding people with pre-existing conditions is both its most politically attractive feature and also the piece of the ACA that requires tax increases and mandates, since it forces insurers to pay for sicker and costlier patients. Thus, that ban is also politically costly for Republicans to remove, but also could destroy the health-care system if they repeal the more unpopular taxes and mandates while keeping it.
In the end, the debate between Cruz and Sanders didn’t shed much light on how Republicans might solve that core paradox of repeal efforts. Cruz’s promises only further clouded the status of Obamacare, even as confusion abounds about the health law. But his inability to provide firm details on a timeline or which plan might win out as a public face for Republican efforts on a prime-time show shows the obvious: Nobody knows.
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