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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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Republicans Will Own Whatever Happens to the ACA and Health Care Reform

As has become clear, “Repeal and Replace” of the Affordable Care Act (ACA), a mantra that provided such a unifying theme for Republicans when Democrats controlled the White House, has been much harder than Republicans expected when they achieved “full control” of the government. Republicans were barely able to pass a health care bill in the House despite their substantial majority over Democrats (240-194) and the Senate fell short of passing the so-called “skinny” repeal bill, HR 1628, which repealed only a limited portion of the ACA.


Because House Republicans had worked on a broad agenda for change in 2016 under the leadership of Paul Ryan, the challenge in the House was somewhat surprising—perhaps caused by the understanding that an affirmative vote for repeal was no longer merely symbolic but might become law. Moderates, who previously had supported their leadership, were uneasy by the Congressional Budget Office projection that up to 23 million more people would be uninsured within a decade as a result of the House legislation. Conservatives wanted even more of the ACA repealed than was possible with the constraints in the Senate, which was focusing on budget-related legislation that could be passed with a simple majority.

The Senate’s inability to pass legislation was less of a surprise, given that the 52 Senate Republicans barely outnumber the 46 Democrats and 2 Independents, and because Senate Republicans had no history of agreeing to the provisions of a replacement ACA bill. Although 3 Republican senators (Sens John McCain of Arizona, Lisa Murkowski of Alaska, and Susan Collins of Main) voted against HR 1628, along with all 48 Democrats, it’s unclear whether other Republicans who had voiced objections to the bill might have been prepared to vote “no” if Sen McCain had not done so.

What Next?

Despite President Trump’s persistent bashing of the Senate leadership for failure to repeal the ACA and his prodding them to try again, another repeal effort led by Sens Lindsay Graham (R, South Carolina) and Bill Cassidy (R, Louisiana) did not fare any better. Among the many challenges for Republicans is that their “repeal and replace’ legislation is viewed unfavorably by most of the public, who think these plans are not consistent with President Trump’s campaign promise of new legislation providing better coverage at less cost.

According to July polling from the Kaiser Family Foundation (KFF), 61% of the public held unfavorable views of the repeal and replace plans (up from 55% in May and June) and 65% opposed reductions in the federal funding of Medicaid, which was an important part of both the House and Senate replacement bills. Furthermore, a KFF poll in August found that 57% of the public want Republicans to work with Democrats to improve the ACA, which clearly has not happened to date.

Ironically, the ACA, disapproved by the majority of US consumers for most of its existence, has become more popular with the public as its survival has been increasingly threatened. Although the public’s attitudes toward the ACA remain deeply divided, a slight majority (52%) of the population now favor it.

What Should Happen?

No major legislation has become a stable part of the social fabric without significant support from both major political parties. Thus, for health care reform to become part of the legislative landscape, Republicans and Democrats will need to find a way to work together. This means that unlike the Democrats’ passage of the ACA and Republican attempts to repeal it, relying on a single-party vote, Republicans and Democrats will need to work together in crafting the next round of health care legislation.

The most immediate need is for Congress to pass measures that would increase the stability in the insurance exchanges and in individual insurance premiums rates. Once this market has been stabilized, it would be appropriate for Congress to focus on achieving longer-term goals, such as reducing health care costs (and thus health insurance premiums) and broader reforms in how health care is delivered.

Fortunately, a variety of efforts are under way that focus on both short-term and long-term policy recommendations that would address these goals.

Inside Congress, Sen Lamar Alexander (R, Tennessee), chair, and Patty Murray (D, Washington), ranking member of the Senate’s Health, Education, Labor and Pensions Committee have called for bipartisan efforts in moving forward health care reform legislation, and scheduled a series of hearings that began right after Labor Day. In another effort, the Problem Solvers Caucus, a bipartisan group of 40 members of the House led by Josh Gottheimer (D, New Jersey) and Tom Reed (R, New York), are trying to salvage some of the proposals that have gained broad public and Congressional support. These include continuing the ACA subsidies, or cost sharing reductions (CSRs), that reduce copays and deductibles for lower-income people who get insurance through the ACA marketplaces, and setting up a “dedicated stability fund” to support state efforts to reduce premium costs and limit losses for insurers.

Most recently a bipartisan group of 8 governors, led by Govs John Kasich (R, Ohio) and John Hickenlooper (D, Colorado), released a health care plan that also propose extending funding for the CSR for 2 years and for establishing a fund to stabilize exchanges among other proposals.

There are also a variety of efforts going on outside of Congress that contain many similar elements. I have been involved with 2 such efforts. One is the Health Reform Roundtable, a project of the Convergence Center for Policy Resolution, which released a statement in early August on general next steps. These were supported by 9 policy analysts who have worked in both Republican and Democratic administrations and with members of Congress from both parties.

A second such group is the Bipartisan Policy Center’s Future of Health Care initiative. This initiative is led by 4  cochairs—former Sens Tom Daschle (D, South Dakota) and Bill Frist (R, Tennessee), former acting Centers for Medicare & Medicaid Administrator Andy Slavitt, and me—and includes 10 health policy experts. The BPC released a set of short-term and long-term policies and recommendations in late August containing many of the recommendations that were in the proposal from the governors’ group.

However, even with these increasing attempts to work in a bipartisan manner, it is very difficult for legislation to move forward without the active involvement of Congressional leadership.  And that’s the one element that remains missing—from both sides of the aisle. Maybe that will change.

About the author: Gail Wilensky, PhD, is an economist and Senior Fellow at Project HOPE, an international health foundation, and also cochairs the Bipartisan Center’s initiative on the future of health care. She directed the Medicare and Medicaid programs, served as a senior adviser on health and welfare issues to President George H. W. Bush, and was the first chair of the Medicare Payment Advisory Commission.  She is an elected member of the Institute of Medicine. (Image: Ted Grudzinski/AMA)
Note: This post was updated on September 27 to note that the attempted ACA repeal effort in late September was unsuccessful.
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