Republican promises to rip up President Barack Obama’s signature health care overhaul have formed the spine of their pitch to voters since the law’s 2010 passage. Now, with unified control of Washington finally in hand, the GOP faces the daunting prospect of delivering. And it’s already finding out that replacing an intricate framework for one-sixth of the economy is easier said than done.
President Donald Trump has set the bar, pledging in his first post-election press conference “a health care that is far less expensive and far better”—and soon. Some congressional Republicans want to slow down the process to allow the party more time to forge consensus, a delay that seems likely. But even with an extension, the challenge remains maddeningly complex. Key Republicans in the administration and on the Hill have committed to ensuring that none of the estimated 20 million Americans who have gained coverage under the Affordable Care Act will lose their care. And policymakers on the right agree on the need to preserve some of the law’s hallmark consumer protections, including the ban on denying coverage for those with preexisting conditions and the provision allowing young people to stay on their parents’ insurance until they’re 26. At the same time, the party is eager to scrap the least popular pieces of the law (think: the individual mandate) that help the private market cover the cost of the coverage expansions.
As Obamacare repeal progresses, Republicans may find marginal tweaks more practicable than a wholesale gutting.
Can the GOP accomplish both? Not without significant tradeoffs, and Republicans are still working out how to make up the gap. It appears they will do so in part by allowing insurers to charge older people more while paring back plans for younger, healthier enrollees. And they could allow insurers to jack up premiums on sick people who don’t maintain continuous coverage. Those who lose their coverage, fall ill, and then can’t afford to buy into the individual market could be eligible for a “high-risk pool” designated for the neediest patients—a popular conservative idea before the health care overhaul. But those programs have historically gone underfunded. “There is definitely a need to understand how these pieces go together,” says Sandra Hunt, a health care reform specialist with PwC.
GOPers are also eyeing major cuts to Medicaid. The ACA dramatically grew the federal insurance program for the poor, accounting for roughly half of the coverage expansion the law achieved. Most Republicans would like to see it transformed into a block-grant program to give states greater flexibility in administering the funds. They would also cap the growth in federal support, putting an increasing squeeze on states to come up with savings.
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Finally, Republicans are likely to get stingier with the tax credits that the current law offers to help people afford insurance, though the details remain a point of contention within the party. Indeed, no element of the Republican replacement plan is fixed. “We’re at the talking-point level right now,” says Larry Levitt, a top health policy adviser in the Clinton administration now with the Kaiser Family Foundation. “We’re at the beginning of the beginning of the debate.” As it progresses, Republicans may find marginal tweaks more practicable than a wholesale gutting. That is, their best repeal-and-replace strategy may be simply to “don’t” and say they did.
By the Numbers
Six years after its passage, the Affordable Care Act is showing that it’s far from perfect. But replacing such a complex law on an accelerated schedule presents steep political and practical problems.
22%: The amount the average cost of health insurance under the Affordable Care Act is expected to rise in 2017, though for many that will be offset by higher subsidies. Rising premiums have driven popular discontent with the program.
18 million: Number of Americans the Congressional Budget Office said could lose their health insurance in one year after major provisions of Obamacare are repealed and not replaced.
100: The number of days that House Speaker Paul Ryan has given for repealing and replacing the law, though most health care experts believe that’s unrealistic: Too many questions about that elusive replacement remain.
A version of this article appears in the February 1, 2017 issue of Fortune with the headline "Repeal Is Easy. Replace? Not So Much."