Gridlock in House stalls Trump's pledge to repeal Obamacare
As a candidate for president, Donald Trump said that "real change begins with immediately repealing and replacing the disaster known as Obamacare."
On March 24, the nation learned that it's not happening immediately. And the road forward isn't clear either.
Capping a frenzied week of negotiations between three House Republican factions -- the party leadership, the hardline conservative House Freedom Caucus, and members of the more moderate, pragmatic wing of the party -- House Speaker Paul Ryan, R-Wis., announced that he would not bring the American Health Care Act to the floor for a vote, as he had planned.
That March 24 announcement came one day after the floor vote had been pushed back to allow for last-minute changes and arm-twisting, and half a day after Trump had issued an ultimatum to House Republicans -- pass the bill or he'll move on.
In the run-up to Ryan's announcement, vote counting by media outlets had concluded that the House GOP would lose too many votes to pass the bill if it tried.
"We came really close today, but we came up short," Ryan said at a press conference. "I will not sugarcoat this. This was a disappointing day for us."
For members on the party's right flank, the American Health Care Act left in place too much of the infrastructure of the Affordable Care Act, President Barack Obama's signature health care law and the target of intense Republican opposition for seven years.
But more moderate Republicans -- especially those serving in Democratic-leaning states and districts -- feared the bill would have taken away insurance from too many Americans. The Congressional Budget Office projected that 24 million more people would be uninsured by 2026 as a result of the bill.
Reconciling the concerns of those two groups proved impossible for Ryan and his team of whips.
Even if the bill had passed the House, it faced rough sledding in the Senate, where several senators were already voicing opposition similar to the House factions. The GOP has only 52 votes in the Senate, meaning that the party could not afford to lose more than two votes either from the right or the center.
It was not immediately clear how congressional Republicans would proceed with efforts to repeal and replace the Affordable Care Act. There is no legislative reason that they could not produce a new bill, but that bill would have to compete with other legislative priorities, such as a tax overhaul or an infrastructure package, for congressional time and attention.
House Minority Leader Nancy Pelosi, D-Calif., called the Republican decision to pull the bill "a victory for the American people." Pelosi was a key player in passing the Affordable Care Act when she served as House Speaker in 2009 and 2010, and her ability to keep a united front among Democrats forced the Republican majority to find enough votes to pass the measure only within its own conference.
As for Trump, he used the bully pulpit to push for the bill, and Ryan thanked him for his efforts as he announced the bill's failure. "The president gave his all in this effort, he did everything he possibly could to help people see the opportunity we had with this bill," Ryan said.
After Ryan's announcement, Trump said from the Oval Office that Obamacare is "exploding now" and he urged Democrats to "get together with us and get a real health care bill." He added that he wants to focus next on tax reform.
Our long-standing policy is to rate promises based on outcomes, not presidential intention. Trump won't be able to repeal Obamacare without direct action from Congress.
With no clear path forward after this major setback, we are moving this promise to Stalled.
Paul Ryan, remarks at a press conference, March 24, 2017
Nancy Pelosi, remarks at a press conference, March 24, 2017
Donald Trump, remarks from the Oval Office, March 24, 2017
Trump signs executive order on Obamacare; impact unclear
On his first day in office, President Donald Trump signed an executive order that gave federal agencies broad authority to defer or delay any part of the Affordable Care Act that costs anybody any money.
More formally, the order tells agencies they can "waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications."
That's a mouthful, but what does it mean, and how far does it go to repeal Obamacare?
Larry Levitt, senior vice-president at the respected and neutral Kaiser Family Foundation, said in a series of tweets that while the impacts are unclear, it shows the administration is "moving to unwind the Affordable Care Act, but it won't be immediate."
Levitt added, "One sure outcome is it creates uncertainty for insurers at a critical time."
Health care analyst Sabrina Corlette at Georgetown University echoed Levitt's point.
"For insurers already uncertain about their future in the Affordable Care markets, the uncertainty this executive order generates doesn't help," Corlette said. "At a minimum they'll have to factor it into their 2018 premiums, which are due to be filed by May 3 in most states."
Robert Laszewski, a health care policy consultant who takes a dim view of Obamacare, said the action raises a host of questions and gives little guidance.
"How will they expect the new Secretary of Health and Human Services and the IRS commissioner, for example, to interpret this?" Laszewski asked. "Just exactly what are they trying to accomplish? Do they only want to make things easier for those in the market, or are they out to just plain blow up Obamacare as soon as possible?"
The reaction from the insurance industry trade group America's Health Insurance Plans has been subdued. The group issued a short statement saying, "We have been meeting with policymakers to offer our recommendations for a better marketplace, and we have found them to be highly engaged and focused on finding real solutions."
Some analysts, including Joe Antos at the market-oriented American Enterprise Institute, see more symbolism than substance in Trump's action. Antos told us that practically speaking, the order doesn't move the ball forward at all toward the goal of repealing the Affordable Care Act. Agencies already had wide latitude on enforcing the law that everyone have insurance or granting states exemptions to Medicaid rules.
"It doesn't create any new authority for any executive branch agency," Antos said. "It basically gives them the instruction to do your job."
The executive order itself only affirms the general policy thrust that everyone understood from Trump's campaign, Antos argued. As far as real change goes, he said, the White House lacks the people to actually green light any specific move.
"They won't have a full team of people until the end of February or even later," Antos said. "When you're operating without a full team, you won't waste time with small stuff anyway. You will focus on what matters most because that is where the money is."
Nicholas Bagley, a law professor at the University of Michigan, posted an assessment that largely agrees with Antos. "For now, the executive order hasn't changed anything," he wrote.
But one element in particular has Bagley worried. The IRS enforces the individual mandate. If the agency plainly states that it won't, insurance mayhem could follow.
"The insurance markets in many states could go into a tailspin," Bagley wrote. "Rates for 2018 will skyrocket, and some insurers could fold."
But that hasn't happened yet.
We continue to rate this promise In the Works.
White House, Executive order on ACA regulations, Jan. 20, 2017
Incidental Economist Blog, Trump's executive order on Obamacare, Jan. 21, 2017
Incidental Economist Blog, Executive actions Trump could take to change the ACA, Jan. 23, 2017
New York Times, What Does Trump's Executive Order Against Obamacare Actually Do?, Jan. 21, 2017
Larry Levitt, tweets, Kaiser Family Foundation, Jan. 21, 2017
Email interview, Sabrina Corlette, program director, Center on Health Insurance Reforms, Georgetown University, Jan. 23, 2017
Email interview, Robert Laszewski, CEO Health Policy and Strategy Associates, Jan. 23, 2017
Email interview, Melinda Buntin, Chair, Department of Health Policy, Vanderbilt University School of Medicine, Jan. 23, 2017
First steps to a repeal are under way in Congress
The quest to repeal and replace the Affordable Care Act began even before Donald Trump was sworn in as president.
More than two weeks before Trump's inauguration, the Senate made its first move, approving a procedural motion on Jan. 4 to start debate on a budget resolution.
Passing a budget resolution is a key step in repealing President Barack Obama's signature health care law. It allows the Republican majority in Congress to repeal sweeping portions of the law with just 51 votes in the Senate. This process, known as reconciliation, saves the majority from having to round up the 60 votes required to break a filibuster -- a much tougher challenge.
On Jan. 12, the Senate passed the budget resolution itself, 51-48. Every Democrat voted against it (except for Sen. Dianne Feinstein, D-Calif., who was recuperating from surgery). The only Republican to cross party lines to vote with Democrats was Sen. Rand Paul, R-Ky., who had expressed concerns about repealing the law without a replacement ready to go.
The budget resolution includes instructions that provide the tools necessary to repeal the law.
Among other things, it instructs the Senate Finance Committee and the Senate Health, Education, Labor and Pensions Committee to submit legislation to the Senate Budget Committee by Jan. 27.
The following day, Jan. 13, the House took up the budget resolution, as is required before the reconciliation process can begin. It passed, 227-198, with nine Republicans siding with Democrats and no Democrats siding with Republicans. The resolution directs the House Energy and Commerce Committee and the House Ways and Means Committee to submit legislation to the House Budget Committee by Jan. 27, 2017.
With the budget resolution out of the way, the next step is to draw up an actual reconciliation bill. The reconciliation process is hardly unknown in the context of the health care law: The Democrats used it to pass the ACA in 2010 after they lost their 60-vote Senate margin in a special election.
Still, using reconciliation to repeal the Affordable Care Act has its challenges. While the ACA has a multitude of provisions, the reconciliation process can only address matters related to federal spending and taxes. (The final judgment on what qualifies for inclusion lies with the Senate parliamentarian.)
That means that payment and tax provisions can be rewritten through a reconciliation bill, but other elements of the law not involving the federal budget would have to wait for a separate bill -- one that would almost certainly need to be passed with 60-vote majority.
So it will be much easier for Congress to pick apart the law ("repeal") than enact new legislation ("replace").
Some Republican senators -- including Susan Collins of Maine, Tom Cotton of Arkansas and Paul of Kentucky -- have urged their colleagues to repeal the law only after a credible replacement alternative is ready. Similar sentiment exists in some portions of the House Republican Conference, though the GOP's wider margin in the House make that chamber less of a worry for repeal-and-replace backers than the Senate.
Notably, Trump told the New York Times that he, too, wants a replacement in short order.
"Long to me would be weeks," Trump said. "It won't be repeal and then two years later go in with another plan." Rather, he said, "the 'replace' will be very quickly or simultaneously, very shortly thereafter."
But no such consensus Republican replacement plan has emerged to date, much less a plan that might attract some Democratic support. And getting a credible replacement plan in place by Jan. 27, or even a month or two after that, is considered a heavy lift, given the complexity of the policy task and the fault lines between lawmakers. Some are speculating that the Jan. 27 deadline will be moved.
So House and Senate Republicans have laid the groundwork for repealing at least some of the key tax-and-spending elements of the ACA, but a full "repeal and replace" is much further away and could remain tricky for both procedural and substantive reasons.
Still, this is enough to rate this promise In the Works.
CNN, "Senate Republicans take first step to repeal Obamacare," Jan. 4, 2017
Los Angeles Times, "Republicans take first step to repeal Obamacare, with a long way to go and no clear path," Jan. 12, 2017
CNN, "House takes first step towards repealing Obamacare," Jan. 13, 2017
Politico, "Trump: Quickly repeal and replace Obamacare," Jan. 10, 2017
Politico, "How the GOP plans to repeal Obamacare: A step-by-step primer," Jan. 11, 2017
The Atlantic, "The Limits of Using Reconciliation to Repeal Obamacare," Jan. 13, 2017
Email interview with AshLee Strong, spokeswoman for House Speaker Paul Ryan, Jan. 19, 2017
Email interview with Don Stewart, spokesman for Senate Majority Leader Mitch McConnell, Jan. 19, 2017
Trump wants to 'repeal and replace' the Affordable Care Act, quickly
Following the Republican playbook, Donald Trump promised as president to repeal the Affordable Care Act and to replace it with something that emphasizes free market principles.
"Real change begins with immediately repealing and replacing the disaster known as Obamacare," Trump said at a Nov. 7, 2016, rally in Michigan.
Currently, 20 million people have health insurance under President Barack Obama's signature law, and the uninsured rate is below 9 percent, a record low. Repealing and replacing Obamacare would require lawmakers to figure out whether they will cover those people, and if so, how.
WHY HE'S PROMISING IT
The Affordable Care Act isn't popular. Polling conducted in 2016 shows that Americans are divided on the law.
And the law has some problems. Despite provisions aimed at curbing rising health care costs, premiums for plans on HealthCare.gov are expected to go up an average of 22 percent in 2017. Insurance companies have pulled out of the marketplaces in 29 states.
HOW MUCH WOULD IT COST
Trump has several policy ideas for what the health care law replacement should include. He suggests allowing providers to sell insurance across state lines, making it so individuals could deduct premium payments from their tax returns and requiring price transparency from health care providers. He also proposes block-granting Medicaid to the states and encouraging health savings accounts.
Trump's proposals could increase the uninsured population by 25 million people and increase the federal deficit by up to $41 billion, according to an independent analysis by the Commonwealth Fund and RAND .
WHAT'S STANDING IN HIS WAY
Republicans have tried and failed dozens of times to dismantle the law in the past. But now with a Republican president and control of both the House and Senate, repealing the law is a more achievable goal.
"It's a pretty high item on our agenda, as you know. And I would be shocked if we didn't move forward to keep our commitment to the American people," said Senate Majority Leader Mitch McConnell at a Nov. 9, 2016, press conference.
However, Republican lawmakers haven't yet figured out exactly what the replacement will look like. They also face the possibility that Democrats will filibuster and block a full repeal.