Imagine 2013: The House succeeds in
partially repealing Obamacare, and only the Republican Senate
blocks its path to completely rescinding healthcare
Flash forward. It’s January 2013, and Republicans have
just regained the White House (pick your candidate), retained
control of the House and selected Kentuckian Mitch McConnell as
the new Senate Majority Leader. But what will the GOP
majorities be able to do, or have the stomach to do, to roll
back President Obama’s signature legislative achievement:
The Patient Protection and Affordable Care Act?
Putting the toothpaste back in the tube will be difficult on
multiple fronts. Even in a GOP sweep, Republicans are highly
unlikely to gain the 60 votes necessary for a governing
majority in the Senate, and it’s hard to imagine a single
Democrat who wouldn’t filibuster any such effort. So
outright repeal is implausible.
Just as unlikely are the chances for enactment of the
pervasive GOP theme to dismantle the employer-provided group
health insurance marketplace in favor of a
“consumer-driven” individual responsibility
approach. The marketplace disruption of such a reform would be
massive, and the political consequences significant. More
importantly, the numbers of votes required for such a tidal
shift just won’t be there.
The enactment of the healthcare reform law marked the first
time that a major entitlement was approved on a purely partisan
basis. Extraordinary parliamentary procedures were deployed by
Democrats who had commanding majorities in both chambers and an
administration eager for a signature accomplishment. While The
Council was able to defeat several elements of the legislation
that were egregious (a broker comp regulatory bureau at HHS,
anyone?), the law remains dramatic in its sweep and
consequences for our industry and for all Americans.
Republicans may be committed to upending the law, but there
are many layers to this onion.
Market reforms. The
elimination of pre-existing conditions restrictions, the
“slacker” provision for kids up to 26, and other
changes that took place shortly after the healthcare bill was
signed into law are all popular and unlikely to be eliminated.
Incentives for preventive
care. This is about the only area of the new law that
Council member brokerages support. They, too, are popular and
aren’t going away.
Development of exchanges. This
is the trickiest and most speculative part. Many state leaders
have balked at establishing exchanges unless they’re
given more flexibility over the administration of Medicaid. A
couple of states have been outright hostile. But virtually
every state has accepted federal grant money to prepare for
enacting their exchanges in 2014. The Utah model of a
relatively simple Internet portal for consumers to shop for
coverage is popular even among Obama’s harshest critics.
Meanwhile, many Council member brokerages have been helping set
up and administer private exchanges. The landslide election of
Republicans won’t stop this momentum, even if skeptics
liken the exchanges to the failed experiments of Multiple
Employer Welfare Arrangements in the ’80s.
Subsidies for individuals in
exchanges. This is the area where Republicans are likely
to roll back the legislation, especially as the subsidies under
the law graduate to as much as 400% of the poverty line. With
the fiscal crisis getting worse, Democrats might agree to kick
the can down the road on subsidies for a few years. The
elimination or radical rollback of subsidies will significantly
diminish the attractiveness of exchanges as an alternative to
the employer-provided group marketplace.
Accountable Care Organizations
(ACOs). This is the most elaborate
“cost-control” aspect of the law. An ACO is a
network of doctors and hospitals that share responsibility for
providing care to patients. In the new law, an ACO would agree
to manage all of the healthcare needs of large groups of
Medicare beneficiaries for a period of years. Republicans
believe that oversight of ACOs will be a massive bureaucratic
nightmare and will erode the number and competitiveness of
providers. Depending on the scope of any GOP victory in 2012,
ACOs could be on the chopping block.
Medical malpractice reform.
Democrats were true to their trial lawyer patrons when passing
healthcare reform. Republicans, given the opportunity, would
enact major tort reform. But there is a political catch: GOP
leaders—I know because I’ve heard it expressed
loudly, if behind closed doors—remain furious at the
major medical organizations for being co-opted into supporting
the healthcare law. Rescuing the docs is not their highest
Individual and employer mandates for
coverage. In the unlikely case that the Supreme Court
overturns the individual mandate as unconstitutional, many
speculate that the entire healthcare law will unravel. Much
hinges on the mandates, which, though unpopular, might be the
law’s most legally defensible provisions. If the Supreme
Court doesn’t change them, Republicans in 2013 would vote
to overturn them. Put on the spot, a handful of Senate
Democrats could make the Republican effort to repeal mandates
So, for the next 13 months, we’re going to hear
Republicans call for the repeal of Obamacare. But they are
unlikely to fully achieve it.
Wood is The Council’s senior vice president of