WASHINGTON - Congressional Republicans, despite pledging to quickly repeal the Affordable Care Act, are struggling with what parts of the law to roll back and how to lock up the votes they will need, particularly in the Senate, to push their ambitious plans.
Settling these questions may delay any major repeal vote for months. Just as importantly, a protracted debate could force President-elect Donald Trump and GOP lawmakers to preserve parts of the health care law they once swore to eliminate. And this all must be resolved before they even turn to the question of how to replace the law.
"Repeal is not going to be as simple as some people might have thought," said G. William Hoagland, senior vice president at the Bipartisan Policy Center.
"There are a number of Republicans, particularly in the Senate, who are going to be very nervous about voting to repeal something without knowing what this process may ultimately produce. ... It could get a lot messier than people appreciate."
Amid the simmering internal GOP discussions, Trump has said little about how he wants to approach repealing and replacing the health care law, though he has kept up his criticism. Tuesday on Twitter, he called the law "lousy healthcare."
Trump is sending Vice President-elect Mike Pence, a former member of Congress, to Capitol Hill on Wednesday to meet with House Republicans to discuss the planned repeal push.
Among other things, Republicans are still debating whether to scrap hundreds of billions of dollars in taxes that have helped extend health insurance to more than 20 million previously uncovered Americans, driving the nation's uninsured rate to historic lows.
That money is viewed as critical to paying for any replacement that Republicans ultimately may develop and has already prompted several GOP lawmakers to voice misgivings about eliminating the tax revenues.
Some in the GOP, particularly in state governments, also are deeply concerned about rolling back federal aid that has allowed states to cover more low-income Americans through Medicaid.
Thirty-one states, including many with Republican governors, have expanded Medicaid through Obamacare and could lose billions of dollars if the law is cut back.
Adding to the uncertainty, Sen. Rand Paul, R-Ky., one of the Senate's most conservative members, urged Congress on Monday not to repeal Obamacare without first developing a replacement.
In Washington, Republicans are also struggling to figure out what to do with Obamacare insurance marketplaces that they tried for years to dismantle. GOP leaders now are trying to figure out how to prevent their collapse.
Insurance experts, including leading industry officials, have repeatedly warned Republicans over the past several months that repealing the health law without a replacement risks destabilizing insurance markets and will push many insurers to simply stop selling health plans.
"We do not support this approach to repealing and replacing the ACA because it carries too much risk of unnecessary disruption to the existing insurance arrangements upon which many people are now relying to finance their health services, and because it is unlikely to produce a coherent reform of health care in the United States," Joseph Antos and James Capretta of the conservative American Enterprise Institute wrote in the journal Health Affairs.
Under the strategy being discussed, the House and Senate over the next couple weeks will pass what is known as a budget resolution that will direct Congress to develop a repeal bill through a process called budget reconciliation.
The House would then craft the repeal legislation, pass it and send it to the Senate. Under budget rules, Republicans, who have a 52-48 edge in the Senate, would need only a simple majority to pass the bill and send it to Trump.
But this approach is fueling an escalating criticism from health care groups representing doctors, hospitals and patients, including the American Diabetes Association and the advocacy arms of the American Cancer Society.
This week, four more leading physician groups urged congressional leaders not to repeal the law without first developing a replacement.
Credit: By Noam N. Levey - Washington Bureau