Obamacare Policy Options: Repair or Wreck

The politics of repealing the Patient Protection and Affordable Care Act have soured, leaving President Trump and repeal-minded Republicans in Congress with few paths forward on healthcare reform.

With last week's collapse of Obamacare repeal-and-or-replace efforts in Congress, the Republican Party's options have dwindled to repair or wreck, a trio of DC healthcare-policy watchers says.

"Republicans have not been able to pass several versions of replace. They have tried a big version. They have tried a skinny version. They have tried repeal-only. Instead of repeal-and-replace, it's time to move to repair," Earl Pomeroy, a former Democratic U.S. representative from North Dakota, told HealthLeaders today.

At this point, any repeal effort appears doomed, the ex-president of the National Association of Insurance Commissioners says.

"In healthcare, good policy is good politics. The lesson we learned on repeal-and-replace is the policy was not very good. It threw a lot of people out of coverage. The public didn't like it; therefore, the politics behind repeal-and-replace were lousy."

Patient Protection and Affordable Care Act (PPACA) is politically primed for repair—even for Republican Party lawmakers and voters who have opposed the PPACA for the past seven years, Pomeroy says.

"The politics are clearly on the side of repair. We have moved past repeal-and-replace. Now, the options are wreck it or repair it. The politics are very poor on the wreck-it scenario. With the governing power held exclusively by the Republican Party in the presidency, House, and Senate. They will be held responsible for actions that wreck the insurance exchanges."

Finding Healthcare Reform Common Ground

There does not appear to be a legislative path forward for Republican lawmakers to repeal the PPACA, Nicholas Manetto, principal at Faegre Baker Daniels Consulting in Washington and former press secretary for a GOP congressman, told HealthLeaders today.

"I tend to agree with the take of several senators in leadership that unless something shifts to move a no vote to yes, there is not much value in pursuing a subsequent vote."

The legislative logjam presents an opportunity for Democratic and Republican lawmakers to stand on common ground and cut a deal on healthcare reforms, according to Pomeroy and Merrill Matthews, PhD, resident scholar at the Institute for Policy Innovation in Irving, TX.

Members of Congress on both sides of the aisle held several shared policy positions on healthcare before passage of the PPACA in 2010, Matthews told HealthLeaders today.

"There has always been support for addressing the problem of the uninsured. There was widespread support among Republicans and Democrats on providing some kind of subsidy to lower-income people to make sure they could afford health insurance. There was pretty wide report for repairing the safety net—you had 35 high-risk pools in the states."

Pomeroy says the commercial insurance market and Medicaid are two crucial areas where the rival parties in Washington have common interests among their home-state constituents.

"On insurance, the debate so far has shown there is enduring support for insurance coverage of pre-existing conditions. Most people think that if you have a health condition you should still be able to buy coverage. So you have to look at how you can make insurance markets function when you can't control the risks you have coming on the books. …

"The Medicaid component of the Affordable Care Act extended the ability of people with very modest incomes to finally get coverage, and the public is determined that that coverage should continue. That was fought over literally for months. … In the end, the Republicans could not get the votes to phase it out. That means that states that have not extended Medicaid may want to take another look at it."

While the Republican Party's healthcare proposals languish on Capitol Hill, Matthews says the Trump administration has a golden opportunity to broker a historic healthcare deal with Democratic lawmakers, as long as Donald Trump sits on the sidelines. "If Trump assigns cutting a deal to Mike Pence, he may be able to get it done. Trump seems too volatile."

He says the president should borrow a page out of his predecessor's playbook from early 2010, when Barack Obama invited Republican and Democratic lawmakers to the White House for discussions on healthcare reform.

"I think it was all for show, but Obama was always presidential. Trump can be presidential at times; but, at other times he can't. You never know which Trump is going to come out."

Ironically, an Obamacare-wreck strategy that ends federal subsidies on the insurance exchanges could be a route to repairing the PPACA, Matthews says.

"If Trump does not continue to make those payments, more insurers will pull out of the exchanges, and faster. It may take the catalyst of more insurers pulling out before they finally come to a willingness to agree on something."