Everything you need to know about the GOP’s plan to repeal Obamacare

Here’s what has already happened — and what could happen next.

Supporters of health care reform rally in front of the Supreme Court CREDIT: AP Photo/Charles Dharapak
Supporters of health care reform rally in front of the Supreme Court CREDIT: AP Photo/Charles Dharapak

Republicans in Congress are moving forward with a complicated process to roll back major aspects of Obamacare — a goal that GOP lawmakers want to accomplish quickly now that Donald Trump has been elected.

The political story is clear: Republicans are eager to get rid of the Affordable Care Act. But the policy reality is much murkier. There’s a long and largely uncertain road ahead before the current law can be changed. And after that, it could take months or even years for those changes to fully take effect.

So what is actually happening in Congress right now? Is Obamacare a done deal or not? And how that will this all affect real people’s insurance plans?

Congress just took the first step toward repealing Obamacare.

Obamacare repeal isn’t hypothetical anymore: Congress has officially put the wheels into motion. This week, both chambers advanced a measure that will serve as the GOP’s vehicle for repealing key parts of the law.

The Senate passed the measure early Thursday morning. The House quickly followed suit and passed the same measure on Friday afternoon. Altogether, only nine Republican lawmakers voted against it.

This measure’s passage doesn’t immediately change anything about the law. But it does pave the way for lawmakers to start working on dismantling the Affordable Care Act as we currently know it.

Republicans don’t have the votes to repeal Obamacare outright.

If Congress attempted to repeal the Affordable Care Act through the typical legislative process, Democrats would be able to block it with a filibuster.

To get around that, the GOP is currently using a process called “budget reconciliation” to roll back the health law. This involves passing a budget resolution instructing congressional committees to write legislation related to issues revolving around spending, revenues, and the federal debt limit. Under the resolution that passed this week, this legislation will also include provisions to undo major portions of Obamacare.

Since budget reconciliation measures are considered “fast-track” legislation, they aren’t subject to the typical filibuster rules in the Senate. That’s why this measure was able to pass the Senate by 51–48 on Thursday.

In some ways, this is familiar territory. Reconciliation is the same avenue that Democrats used to pass the Affordable Care Act in the first place. It’s a way to circumvent the minority party.

Republicans can’t repeal every aspect of Obamacare this way.

Using budget reconciliation means the GOP will not be able to get rid of the entire Affordable Care Act in one fell swoop. Senate rules prohibit lawmakers from writing budget reconciliation measures that include provisions unrelated to spending, revenues, and the federal debt limit.

Many Obamacare policies do fall under the budget umbrella because they relate to the way the government taxes and spends. For instance, Obamacare requires the government to put funds toward subsidies to help low-income people afford insurance plans. And one of the law’s most central provisions, the individual mandate that compels all Americans to purchase health coverage, was ruled a tax by the Supreme Court in 2012.

But a lot of other parts of the law — like the popular consumer protections Obamacare enacted requiring insurance companies to cover people with pre-existing conditions and allowing young adults to remain on their parents’ plans until the age of 26 — aren’t budget related. So these provisions can’t be repealed through the reconciliation process.

Repealing some parts of Obamacare can still hobble the whole law.

The GOP may not be able to repeal the entire Affordable Care Act, but rolling back some parts of the law still threatens to destroy it.

In order to expand access to health care to the Americans who were previously locked out of the system — people who, for the most part, are poorer and sicker than the rest of the population — Obamacare strikes a delicate balance between several different mechanisms. Taken together, these policies have reshaped the insurance industry in important ways.

The law’s different provisions work in concert to ensure that:

  1. Low-income people can afford insurance plans. Obamacare provides tax subsidies to make insurance plans more affordable and expands Medicaid to cover a larger number of impoverished Americans.
  2. Sick people aren’t turned away from buying coverage. Obamacare bans insurers from refusing to offer insurance to people who have pre-existing health conditions.
  3. Insurance companies can maintain the right balance of customers. Obamacare requires everyone to buy insurance, which helps keep insurers’ costs down by balancing out expensive customers (older and sicker people) with cheaper customers (younger and healthier people).

Policy wonks refer to this model as the “three-legged stool.” Essentially, Obamacare can only function with all three of its major initiatives in place. Even if Republicans are cut off just two of the legs — tax subsidies and the individual mandate — the rest of the law will still collapse.

If insurers are still required to cover people with expensive pre-existing conditions, but there’s no longer an individual mandate requiring young and healthy people to buy coverage, it will be disastrous for the overall pool. Without the right balance of sick and healthy people buying their plans, insurance companies won’t be able to keep costs low — and, in what’s ominously called a “death spiral,” insurers will end up setting their premiums higher and higher until no one can afford coverage at all.

It will take a lot of work to turn Obamacare repeal into a reality.

Congress has voted to begin the process of repealing Obamacare. But the budget reconciliation process is pretty complex, and there’s still a long way to go before any Obamacare provisions are actually taken off the books.

Now that the budget resolution has passed, lawmakers will have to get to work writing specific legislation that outlines exactly what is going to be repealed. Four different committees — the Finance Committee and the Health, Education, Labor, and Pensions (HELP) Committee in the Senate, and the Ways and Means Committee and the Energy and Commerce Committee in the House — will be responsible for crafting bills and working to finalize one version to send to the full Senate and full House. Once this legislation passes both chambers, it will head to Trump’s desk.

Even with plenty of GOP support for repealing Obamacare, agreeing on the specific details that should be included in legislation to repeal it will be much, much more complicated than passing the initial budget measure.

There are a lot of opportunities for this process to break down along the way. It could be hard to get lawmakers in different committees to agree on their top priorities. It might take a lot of work to reconcile the Senate and the House versions of the legislation. If the GOP’s repeal bill is projected to add to the deficit, that could be a nonstarter for many Republicans. And, of course, the legislation cannot become so expansive that it ends up violating the narrow rules about what may apply under budget reconciliation.

Republicans say they’ll replace Obamacare with something new. But that’s much easier said than done.

When the new Congress first convened earlier this month, Republicans were very eager to move forward on repealing Obamacare and much less concerned about what would come after that. They suggested they would repeal Obamacare first and figure out how to replace it later — an incredibly risky strategy known as “repeal and delay” that is unpopular among health care experts, the American public, and even moderate Republicans.

At one point, there was so much dissent over the “repeal and delay” strategy that it looked like Republicans might not be able to advance Obamacare repeal at all. The budget resolution almost didn’t clear the Senate.

GOP leaders rectified that issue by changing their tune. Now, Republicans claim they will swiftly replace Obamacare with a new law. House Speaker Paul Ryan (R-WI) has vowed his party will come up with an Obamacare replacement within the first 100 days of Trump’s presidency. Party leaders have eased the concerns of moderate lawmakers by promising to hold a vote on final repeal legislation and a vote on a replacement bill at the same time, pledging that the two steps will come “simultaneously.” This way, Republican leaders say they won’t rip away health care away from their constituents because they’ll have an Obamacare alternative ready to go.

But it’s not at all clear that Republicans will be able to follow through. Coming up with a plan in a matter of weeks is a very ambitious goal considering that the GOP has failed to deliver an Obamacare replacement for the past six years. Despite voting to repeal Obamacare more than 40 times, Republicans have never produced a viable alternative.

There are two main problems that have prevented the GOP from engaging in a real debate about health reform. For one, health policy is complicated — it’s no small feat to figure out how to unwind the maze of laws and regulations that have become entrenched under Obamacare — and the GOP’s proposals haven’t included the requisite level of detail to seriously contend with the messy path forward. And for another, Republicans simply aren’t willing to spend the kind of money it takes to maintain the same access to insurance that’s become the new reality under Obamacare. That’s why all of the health care proposals put forth by Republicans would result in poorer and sicker Americans being left worse off than they are now.

On top of that, separate replacement legislation would need to overcome the 60-vote threshold in the Senate — which means Republicans would need to get the support of at least a few Democratic lawmakers.

This is serious. Obamacare repeal has the potential to affect nearly everyone in the country.

A lot of Americans associate Obamacare primarily with the plans available in the individual market. You may assume that because you didn’t sign up for a health plan through the marketplaces that Obamacare created in each state, the current flurry of activity in Congress won’t affect you.

That’s not entirely true. The Affordable Care Act is a sprawling law that made big changes to the employer-based market as well as the individual market. Even if you aren’t on a so-called “Obamacare plan,” there’s a good chance that Obamacare does affect your plan in some way.

Most Americans under the age of 65 get their health coverage through their job, and thanks to Obamacare those plans are subject to requirements designed to make coverage more comprehensive and more affordable. For instance, employees now have access to birth control without an additional co-pay, have limits on the out-of-pocket expenses they may be charged, and have the option to keep dependents on their plans up to age 26.

These consumer protections can’t be rolled back immediately through budget reconciliation. But due to the widespread chaos that even a partial Obamacare repeal could wreak, none of the law’s current provisions should be assumed to be safe in the long term. If Republicans successfully repeal the bulk of Obamacare, there’s no telling exactly how they may try to reshape the industry industry with subsequent legislation.

The GOP has shown no willingness to offer guarantees in this area. During the bitter fight over the budget measure this week, in a session known as “vote-a-rama,” Senate Democrats offered a series of non-binding amendments to stipulate that consumer protections would be off-limits in any subsequent Obamacare repeal bill. Republicans voted them all down.

Your access to health care is not going to change overnight.

All that being said, it’s important to remember that the government moves slowly and the entire insurance industry can’t change on a moment’s notice. If you rely on Obamacare’s marketplaces for your health care plan, you are not going to wake up tomorrow and suddenly be uninsured.

“Consumers are unlikely to see major changes to their health insurance this year because contracts are already signed and regulations are already in place for this plan year,” reports the New York Times.

Plus, Republicans are already sending signals they want to extend the status quo while they keep working on repeal. According to Politico, Republicans are considering spending up to $9 billion toward health care subsidies to ensure that people can continue to afford plans on Obamacare’s marketplaces. The deeply ironic move — the GOP has spent years railing against Obamacare subsidies, and some House Republicans have sued the government over them — shows that lawmakers are wary to completely disrupt the individual insurance market in the middle of the year.

That doesn’t mean major disruptions won’t happen further down the line, of course. Depending how quickly Republicans are able to move, Americans may start seeing big changes to their insurance in 2018.

Concerned about the uncertain future, some people are wasting no time. According to Planned Parenthood, the organization’s clinics saw a 900 percent increase in demand for long-acting contraception like IUDs in the immediate aftermath Donald Trump’s election.

The people rushing to make appointments to get new IUDs are not being irrational here. It’s not an exaggeration to say that the future of health care hangs in the balance. Frankly, it’s impossible to predict what’s going to happen because Congress hasn’t written specific repeal or replace legislation yet — and even then, we still may not be able to predict how the insurance industry will respond to the proposed changes.

But on a practical level, if you’re trying to plan ahead, you don’t need to make an appointment with your doctor next week. You will likely have the rest of 2017 to prepare for whatever comes next.