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WASHINGTON — Here’s the idea: Swiftly pass a repeal of President Barack Obama’s health care law, perhaps soon enough for Donald Trump to sign it the day he takes the presidential oath. Then approve legislation restructuring the nation’s huge and convoluted health care system — despite Republican divisions, Democratic opposition, and millions of jittery constituents.

What could go wrong?

With Republicans controlling the White House and Congress in January, they’re faced with delivering on their long-time promise to repeal and replace “Obamacare.” Here are hurdles they’ll face:


Speed vs. deliberation

Trump and congressional Republicans will be under intense pressure from their core conservative supporters to repeal Obama’s 2010 health care law — and fast. After all, Congress already sent Obama a repeal bill last January, which he vetoed, and many GOP voters will see no reason for delays this time.

But there probably won’t be anything fast about Congress’ effort to replace Obama’s law, which is likely to take many months.


While the replacement effort is underway, Republicans will risk aggravating up to 30 million people who are covered by the law or buy policies with prices affected by its insurance marketplace. Democrats will be sure to accuse the GOP of threatening the health care of millions.

A solution

Nothing’s been decided, but here’s one likely scenario:

The new Congress, which convenes Jan. 3, tries to quickly approve legislation repealing Obama’s health care law, maybe completing it by Trump’s Jan. 20 inauguration or soon after. But the repeal would not take effect until the future, perhaps a year later, to give lawmakers time to fashion a replacement. The version Obama vetoed had a two-year delay.

Seemingly acknowledging that two-step process, Vice President-elect Mike Pence said Sunday on “Fox News Sunday” that Trump “wants to focus out of the gate on repealing Obamacare and beginning the process of replacing Obamacare.”

Because Republicans will control the Senate by just 52-48, Congress will first have to approve special budget procedures to prevent Democrats from stopping repeal legislation by filibuster. Bill-killing filibusters require 60 votes to end.

But those special rules would apply only to items that affect the federal budget. Republicans, for example, would need a simple Senate majority to end IRS penalties against people who don’t buy insurance but would still need 60 votes — requiring Democratic support — for other changes such as raising limits on older people’s premiums.

House Budget Committee Chairman Tom Price (R-Ga.) says that will restrain Republicans’ ability to ram a “lock, stock and barrel” repeal through Congress.

GOP risks

One GOP danger: Congress and Trump might repeal Obama’s law, but while they’re laboring on a replacement, nervous insurance companies begin pulling out of markets and raising premiums. Insurers have been doing that under Obama, but now it would occur under a Republican government.

Another hazard: Congress’ work could spill into the 2018 campaign season, when the entire House and a third of the Senate face re-election. Republicans will grow increasingly timid about anything that might anger voters.

“We want to be the rescue party instead of the party that pushes millions of Americans who are hanging by the edge of their fingernails over the cliff,” says Senator Lamar Alexander (R-Tenn.), who chairs the Senate Health committee.

GOP pathways

Virtually all Republicans want to get rid of the health law’s mandates that individuals buy coverage or risk IRS fines, and that large employers insure workers.

They also want to erase taxes on higher-earning people and the health care sector. And they’d like to retain parts of the law guaranteeing coverage for people with pre-existing medical problems and keeping children under age 26 on family plans.

Unifying Republicans much beyond that is a work in progress.

Trump’s health care views have varied and lack detail. His campaign website touts tax deductions for health insurance premiums and permitting policies to be sold across state lines. He’d also revamp Medicaid, which subsidizes health coverage for low-income people, directing fixed amounts of money to states and letting them structure benefits.

House Speaker Paul Ryan (R-Wis.) last summer unveiled an outline of the House GOP’s solution, though it lacked cost estimates and details. It would provide tax credits, impose taxes on the most generous employer-provided health care plans, revamp Medicaid and let Medicare beneficiaries pick private plans instead of today’s fee-for-service coverage.

Senate Finance Committee Chairman Orrin Hatch (R-Utah) has also advanced a framework relying heavily on tax credits.

Remaining questions

Thirty-one states — including Pence’s Indiana, where he is governor — plus the District of Columbia have expanded Medicaid coverage to 9 million additional people under Obama’s law. Curtailing that program will divide Republicans.

Taxing the value of some employer-provided health plans, aimed at curbing the growth of costs, is “a political land mine,” says GOP economist Douglas Holtz-Eakin. Republicans have long resisted tax increases.

Obama’s law mandates coverage for individuals because without that requirement many healthy people would forgo policies, driving up costs for everyone else and destabilizing insurance markets. Ryan has proposed shielding people from higher premiums if they’ve had “continuous coverage,” allowing higher rates for people who have not had policies, but Republicans have yet to decide how to keep insurance markets viable.

— Alan Fram

  • The ACA and its ultimate revision is of interest to me. I would be pleased
    to participate formally in this discussion.
    I am beginning my 47th year at Massachusetts General Hospital . During
    that period I was on active reserve duty as LCDR at NRMC Pearl.
    Along with my Officer in Charge Dr. Nowel Howard; and under the Command of Admiral Thor Hanson ( Deceased ) . Dr. Howard and I
    addressed the psychiatric needs of all Naval and Marine personnel and
    their families in Hawaii and Midway. When I returned to
    MGH I joined The MGH Transplant Service and worked with that
    group fulltime until 2013 . I now continue as Associate Professor at Harvard Medical School ; and in part time work in the Psychiatry OPD at MGH. I have a small private practice and continue to look for meaningful opportunities.
    In my Transplant Psychiatry work I played a role in regard to ethical
    issues regarding candidate selection. In 2002 I participated in a
    group organized under the oversight of The New York State Dept. of
    Health in review of changes required following the unfortunate death
    of a living partial liver donor at a major NY Hospital. I am a special
    fan of William James whose ” Pragmatism” led to the conclusion that
    there are many good ideas; but, in the street, things are messy ! I
    am beginning to look at perspectives regarding abortion with a colleague
    who was formally Chief of OBGYN at MGH and Brigham and Women’s
    Hospital. As for change in the ACA I was stunned by a piece in the
    Wall Street Journal that would eliminate or otherwise compromise
    funding for psychiatric care in a new health care plan. This is stunning
    given the impact of psychiatric disorders on medical disability–among
    the top 3-4 causes world-wide. What would omitting psychiatric care
    do to the ultimate contagion in families; and what would it do in regard
    to the untoward social impact when serious illness ( of any nature is
    unmet by available advances in health care. The failure of the ACA
    had multiple cause; the worst of which was Corporatization of Medicine
    by land mines in the ACA that would withhold payment to Hospitals
    if physicians did not fill in all the required forms. This has been destructive
    beyond measure.
    Thanks for the opportunity to respond: Owen Stanley Surman M.D.


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