Obamacare Repeal Collapses Over Republican Divisions Obamacare Repeal Collapses Over Republican Divisions

Obamacare Repeal Collapses Over Republican Divisions

By Grant Huang, CPC, CPMA, Director of Content at DoctorsMangement  

The Senate bill to replace the Affordable Care Act (ACA) appears to be dead as this issue of The Business of Medicine goes to press, leaving the future of American healthcare more uncertain than ever. What isn’t a mystery is the reason for the Senate bill’s demise: Republican division over its provisions.

This included significant reductions to federal Medicaid funding that would hit in 2021, when the bill would convert Medicaid from an open-ended entitlement program into a block-grant program. Instead of the federal government matching state funding with no limit, the bill would allot states a fixed, per-capita amount. “It basically turned into a Medicaid reform effort,” says Jack Hoadley, research professor at the Georgetown Health Policy Institute. “It reflected an ideological belief by many Republicans who don’t believe Medicaid is working and looked to fundamentally change the program.”

Apart from the change to Medicaid, the Senate bill would’ve also eliminated the individual mandate and given states the option to allow insurers to sell much skimpier – and cheaper – coverage. But the overall shape of the ACA would’ve been preserved, Hoadley says. The federal government would still offer premium support, albeit via age-based tax credits instead of income-based subsidies, while the Medicaid expansion would remain for 10 years before being scaled back.

These similarities were the reason for opposition to the bill from conservative Republicans, such as Senators Mike Lee (R-Utah) and Jerry Moran (R-Kans.). In a statement, Sen. Moran bemoaned the “closed-door” process used to craft the Senate bill, which involved only 13 Republican Senators without any Democrats or industry stakeholders. The resulting bill “fails to repeal the Affordable Care Act or address healthcare’s rising costs,” Moran said. “For the same reasons I could not support the previous version of this bill, I cannot support this one. We should not put our stamp of approval on bad policy.”

More moderate Republicans, such as Sen. Susan Collins (R-Maine), were hostile to the bill for precisely the opposite reasons. “We should not be making fundamental changes in a vital safety net program that’s been on the books for 50 years … without having a single hearing to evaluate what the consequences are going to be,” Collins said in a CNN interview.

Final effort to ‘repeal and delay’ also fails

Faced with the narrowest of margins for error and unable to lose a single “yay” vote, Senate Majority Leader Mitch McConnell (R-Ky.) delayed a vote on the bill to give Sen. John McCain (R-Ariz.) time to recover from a surgical procedure. But the additional losses of Sens. Lee and Moran on July 17 sealed the fate of the Senate bill. McCain’s recent diagnosis of brain cancer further throws any attempt to repeal the law into doubt.

McConnell made a last effort to bring a “repeal now and replace later” bill to the floor, but it was torpedoed almost instantly by a trio of Republican senators, including Collins of Maine and Sens. Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska. “I did not come to Washington to hurt people,” Sen. Capito said in a statement. “I cannot vote to repeal Obamacare without a replacement plan that addresses my concerns and the needs of West Virginians.”

Passing a repeal-and-delay bill would also have further destabilized the ACA’s individual insurance market, as it would start the clock ticking on the end of premium support without giving insurance companies any idea of what an eventual ACA replacement would look like.

For his part, President Donald J. Trump did not give up on repealing and replacing the ACA, which was one of his top campaign promises. “We were let down by all of the Democrats and a few Republicans,” he wrote in a July 18 post to Twitter. “We will return. As I have always said, let Obamacare fail and then come together and do a great healthcare plan. Stay tuned!”

More uncertainty now than during ACA’s launch

President Trump’s posts mark the conclusion of a second failed attempt by Republicans to repeal and replace the ACA, despite their control of all three branches of government. As a result, there is more uncertainty now over the future of American healthcare than there was during the birth of the ACA, Hoadley believes.

“In both cases we have a strong partisan divide over the course of health policy,” he says. “But the difference in 2009 and 2010 was that there was a fairly broad consensus then that something had to be done. Now, you have a majority of Republicans saying in polls that they didn’t like these repeal bills, in addition, of course, to most Democrats.”

While the Democrats wound up passing a controversial and partisan bill in 2010, it was clear from the beginning that the status quo was going to change one way or the other, Hoadley says. “Now anything can happen, and there isn’t a decades-long status quo to return to.”

Grant Huang, CPC, CPMA (ghuang@drsmgmt.com).  The author is Director of Content at DoctorsMangement.