GOP Begins ACA Repeal Effort

The Washington Post

Washington — Congressional Republicans on Wednesday launched their long-promised effort to dismantle the Affordable Care Act, even as they acknowledged that they may need several months to develop a replacement along conservative lines.

Signifying how enormous a priority the issue is for the incoming administration, Vice President-elect Mike Pence met privately to discuss it with House and Senate Republicans. He offered no details afterward about what a new health care law might look like but vowed to unwind the existing one through a mixture of executive actions and legislation.

Meanwhile, President Obama made a rare Capitol Hill appearance, meeting behind closed doors with Democrats from both chambers. He urged members of his party not to help the GOP devise a new health care law.

The dueling high-level visits, on the same day that the Senate opened debate on a budget resolution that would begin rolling back the law, highlighted the sharp political fault lines that surround the future of the government’s health policies.

The president, who was accompanied by Senate Minority Leader Charles Schumer, D-N.Y., House Minority Leader Nancy Pelosi, D-Calif., and Rep. Frederica Wilson, D-Fla., as he entered the Capitol, took no questions from reporters before or after the nearly two-hour meeting. But participants said he told members of his party that they did not have to “rescue” Republicans and that they should “stay strong” as the GOP strives to replace the law.

Pence told reporters that he and President-elect Donald Trump would pursue a “two-track approach” to chip away at the ACA, also known as Obamacare, through executive powers and legislation. Trump is “working on a series of executive orders that will enable that orderly transition to take place,” Pence said, and is eyeing other policies that can be reversed.

Although Pence did not identify other policy targets, Republicans from Western states urged him Wednesday to undo some of the public land protections Obama has created through the 1906 Antiquities Act. Other executive actions, including those providing new safeguards for LGBT Americans and curbing greenhouse gas emissions linked to climate change, also could come under fire.

According to a lobbyist in touch with congressional aides on the ACA issue, the Trump transition team has been considering ways to strip down the health benefits that insurers must provide in plans that they sell to individuals and small businesses.

This list of “essential health benefits” was envisioned by the law but was defined in a regulation written by the U.S. Department of Health and Human Services. As a result, the incoming administration could alter it without help from Congress.

Trump took to Twitter on Wednesday morning to urge Republicans to “be careful in that the Dems own the failed Obamacare disaster.” In a dig at Schumer and his allies, Trump added: “Don’t let the Schumer clowns out of this web.”

Less than half an hour after Trump’s social media messages, Schumer tweeted: “Republicans should stop clowning around with America’s health care. Don’t #MakeAmericaSickAgain.”

Schumer and other Democrats echoed Obama, saying they did not feel any responsibility to craft a substitute health care bill.

“If you are repealing, show us what you’ll replace it with. Then we’ll look at what you have and see what you can do,” said Schumer, who met briefly with Pence on Wednesday.

White House press secretary Josh Earnest said Obama told Democrats that they are well positioned to defend the law, which has extended insurance to more than 20 million Americans.

However, Obama also told lawmakers he recognized that he had not succeeded in selling the law to the public. “There was an acknowledgment that so many features were so popular, but there was a failure to communicate that,” said Sen. Jeff Merkley, D-Ore.

Pence, who was greeted by applause as he entered the House GOP meeting with Reince Priebus, Kellyanne Conway and several other future White House aides, made it clear that Trump, starting on the first day of his presidency, intended to embark on an aggressive campaign to reverse executive actions made by Obama.

“They didn’t enumerate a list, just that which came by the pen can die by the pen,” said Rep. Mark Sanford, R-S.C.

The first bill Republicans introduced in the new Senate that convened on Tuesday was budget legislation with instructions for House and Senate committees to begin repealing the Affordable Care Act. The bare-bones spending outline requires members of four committees — Ways and Means and Energy and Commerce in the House; and Finance, as well as Health, Education, Labor and Pensions, in the Senate — to produce bills just seven days after Trump’s inauguration that each would save $1 billion over a decade by slashing elements of the heath care law.

House Republicans tasked with writing the repeal legislation said that no final decisions have been made on what it will include. Rep. Patrick Tiberi, R-Ohio, who chairs a House subcommittee that oversees health care, called the incoming administration’s Jan. 27 deadline “a challenging goal.”

Among the unanswered questions is whether Republicans will immediately end health care taxes, such as an additional 0.9 percent Medicare payroll tax and a 3.8 percent investment income tax, that were created to help pay for the Affordable Care Act. Some Republicans have insisted that the taxes should be eliminated immediately, even if lawmakers decide to delay the repeal of other parts of the law. Others worry that repealing the taxes will make it impossible to pay to keep Obamacare afloat while a replacement is finished.

“We’re not sure yet,” Tiberi said. “There’s just not consensus on this.”

Rep. Chris Collins, R-N.Y., a member the Trump transition team, said in an interview that “we have six months to work out the replacement plan” for the sweeping health care law.

Senate rules allow budget resolutions to pass by a simple majority — a maneuver that guarantees that the chamber’s Democratic minority will not have enough votes for a filibuster to block repeal.

Only changes related to taxes, spending or the long-term federal budget are eligible for the simple-majority treatment, however. Other parts of the law, such as the structure of the insurance marketplaces, probably would require a veto-proof margin of 60 votes in the Senate, a trickier task since the new Senate has 52 Republicans.

Since its passage by Congress in the spring of 2010 — entirely with Democratic votes — the ACA has spurred the most significant changes to U.S. health policy since the creation of Medicare and Medicaid during the Great Society legislation of the 1960s. It also has faced sustained opposition from Republicans, leading to two Supreme Court cases and a lawsuit over cost-sharing subsidies that now is before the U.S. Court of Appeals for the District of Columbia Circuit.

The ACA is best known for having expanded insurance coverage, starting in 2014, in two ways: new marketplaces selling private health plans to Americans who do not have access to affordable health benefits through a job, and an expansion of Medicaid in about three-fifths of the states. The marketplaces got off to a shaky start because of computer dysfunction with HealthCare.gov, the federal enrollment website.

Three years later, the U.S. Census Bureau reported that the nation’s uninsured rate had declined to 9.1 percent, with most of a recent decrease coming from people who bought insurance on their own and more who had joined Medicaid.

The president’s visit to the Hill was part of a broader, last-ditch effort by his administration to preserve a central element of his domestic legacy.

On Wednesday morning, New York Gov. Andrew M. Cuomo drew attention to the stakes for his state by issuing a county-by-county breakdown of the estimated 2.7 million New Yorkers who would lose coverage if the law were repealed. He pointed out that New York would lose $595 million this year in federal money that has helped the state expand its Medicaid program.

HHS officials have been trying to use to their advantage the fact that the change in administrations will take place while the fourth year’s enrollment period for ACA health plans is underway. On Wednesday, HHS released HealthCare.gov enrollment figures showing that 8.8 million Americans chose or were automatically re-enrolled in ACA health plans between Nov. 1 and Dec. 31 in the 39 states that rely on the federal exchange website. That is about 200,000 more than at the same time a year ago, although the proportion of new customers was lower.

The new drive to unwind the health care law will take time. Senate leaders must allow Democrats to offer a nearly unlimited number of amendments before a final budget vote. Democrats plan to use the process, known as a “vote-a-rama,” to offer a long string of potentially toxic amendments that could make it difficult for Republicans to vote for the final legislation, Democratic leadership aides said.