Things are shifting right now on Capitol Hill with regard to Republicans’ previously stated intentions to “repeal and replace” the Affordable Care Act (ACA), often referred to as “Obamacare,” with key Senate Republicans changing their tone, and their pronouncements, on what might happen next. The ACA has been in place since March 23, 2010, when President Barack Obama signed it into law. A focus of Republican opposition ever since then, the ACA became a significant focus of the 2016 presidential election campaign, as Donald Trump and other Republicans vied with one another during the Republican presidential primaries over who might most effectively repeal the law.
President Donald Trump has weighed in, signing two executive orders that are connected to healthcare policy. First, on Jan. 20, just hours after taking the oath of office, President Donald J. Trump signed an executive order, one of his first, giving federal agencies the authority to work within their scope of authority to undo unspecified regulations pertaining to the Affordable Care Act (ACA) of 2010. Exactly how such authority might be used, and under what circumstances and to what extent, was left extremely unclear; but the order did signal Pres. Trump’s previously stated intentions to help to overturn the ACA, though only the U.S. Congress can actually fully repeal the legislation. A second executive order directing a freeze on new regulations pending review, could also impact elements around how the ACA’s regulations might evolve forward.
The first of the two orders directs the Secretary of Health and Human Services (HHS) to work within their scope of authority to undo ACA-related regulations. To some extent, that order awaits the confirmation of Rep. Tom Price of Georgia, whom Trump has nominated as the next Secretary of HHS, but whose nomination has slowed as it has worked its way through the Senate. On Feb. 1, in the face of a boycott of a committee vote by Senate Democrats, Senate Republicans used a procedural maneuver to push the Price nomination out of Senate Finance Committee and forward into the full Senate for a vote. Rep. Price has said that he fully supports repeal and replacement of the ACA, and that as Secretary of Health and Human Services, he plans to assist congressional Republicans in repealing and replacing it.
Now comes a shift in the tenor of the discussion on Capitol Hill. On Thursday, Feb. 2, Kelsey Snell and Mike DeBonis of The Washington Post reported that “Two top Republicans long expected to lead the Senate’s role in repealing the Affordable Care Act said publicly this week that they are open to repairing former president Barack Obama’s landmark health-care law ahead of a wholesale repeal, which has been a GOP target for eight years. Coming one week after a closed-door strategy session in which Republicans expressed frank concerns about the political ramifications of repealing the law and the practical difficulties of doing so, statements this week by Sen. Orrin G. Hatch (R-Utah) and Sen. Lamar Alexander (R-Tenn.) brought into public view the political and policy challenges the GOP is facing,” Snell and DeBonis wrote.
Snell and DeBonis reported on statements made by Sens. Hatch and Alexander, who are the Chairmen of the Senate Finance Committee (Hatch) and of the Senate Committee on Health, Education, Labor and Pensions (HELP; Alexander), respectively, in their story published on Thursday. Those are the two Senate committees that would be responsible for any significant legislative effort to overturn the ACA in whole or in part. In a hearing Wednesday, Alexander said, “I think of it as a collapsing bridge…. You send in a rescue team and you go to work to repair it so that nobody else is hurt by it and you start to build a new bridge, and only when that new bridge is complete, people can drive safely across it, do you close the old bridge. When it’s complete, we can close the old bridge, but in the meantime, we repair it. No one is talking about repealing anything until there is a concrete practical alternative to offer Americans in its place.”
And Hatch, chairman of the Senate Finance Committee — another panel with a crucial role in the effort to repeal the ACA — said Thursday that he “could stand either” repealing or repairing the law. “I’m saying I’m open to anything. Anything that will improve the system, I’m for,” he said.
As Snell and DeBonis noted, “The comments come one month after Republicans in Congress first set out to immediately repeal and replace the Affordable Care Act. While an increasing number of them have expressed concern about how feasible it is, many others, including House Speaker Paul D. Ryan (R-Wis.), remain committed to a wholesale repeal and replacement.” They quoted a statement that Rep. Ryan had made in an appearance Thursday morning on “Fox & Friends,” a Fox News program, in which he said, “There’s a miscommunication going on. If we’re going to repair the U.S. health-care system… you must repeal and replace Obamacare.”
But, faced with public opinion polls showing that the public is becoming more concerned about what ACA repeal might mean—another report by the Associated Press’ Alan Fram and Ricardo Alonso-Zalvidar, published in The Washington Post on Friday, Feb. 3, noted that “A recent Associated Press-NORC Center for Public Affairs Research poll found 53 percent want to keep Obama’s law in some form, and 56 percent concerned that repeal means many will lose insurance.” The article by Fram and Alonso-Zalvidar also noted that, “At a hearing Thursday before a House health subcommittee, Republicans revealed four drafts of potential bills. One would let insurers charge older customers higher rates. Another would replace the law’s unpopular individual mandate with a requirement that people maintain ‘continuous’ coverage if they want to avoid more expensive policies.”
And it is not only in the Senate that the tenor of the discourse has changed in the past week; the same is true in the House of Representatives. In an article that The Hill published on Wednesday, Feb. 1, Peter Sullivan quoted House Energy and Commerce Committee Chairman Greg Walden (R-Ore.), as telling reporters that “I'm trying to be accurate on this that there are some of these provisions in the law that probably will stay, or we may modify them, but we're going to fix things, we're going to repair things. There are things we can build on and repair, there are things we can completely repeal,” The Hill quoted Walden as telling members of the press.
Meanwhile, Capitol Hill sources have reported to Healthcare Informatics the growing spread of sentiment on the part of Republicans in Congress that is backing away from attempting a full-scale repeal of the ACA, with a greater likelihood that what will ultimately happen will instead be a “repair,” as it’s now being called, of the law. That could mean any number of things, including perhaps forcing state insurance commissioners to allow health insurers to offer less-robust health plans across state lines, something that Republicans have long talked about. But those Capitol Hill sources also indicate that the current situation around ACA repeal is in an exceptional state of flux, because of the unsettled political climate, so it is difficult to predict the ultimate outcome, though, they say, comprehensive repeal is looking less likely now than it did even a week ago.
Meanwhile, the internal healthcare system reform elements of the ACA that remain far less controversial than its insurance provisions, might possibly remain largely safe, in any case. Those would include the Medicare program-sponsored value-based purchasing program, the readmissions reduction program, the healthcare-acquired conditions program, and the voluntary programs around accountable care organizations (ACOs) and bundled payments. As Jennifer McLaughlin, senior associate director for governmental affairs at the Englewood, Colo.-based Medical Group Management Association (MGMA) told HCI on Feb. 2, “Our understanding is that wholesale repeal of all of those pieces is unlikely to happen through reconciliation. So we are just looking forward to, once that dialogue does begin as to what the legislative package starts to look like, we look forward to providing input on how Congress can capitalize on that bipartisan initiative to repeal the SGR [sustainable growth rate for physician payment under Medicare] and create MACRA [the Medicare Access and CHIP Reauthorization Act of 2015], and help to reduce excessive regulation, and support business-friendly policies. But at this point, we don’t see too many of those issues being impacted through the reconciliation process.”
McLaughlin did tell HCI that she expects Rep. Price, should he be confirmed as HHS Secretary, to potentially make “wholesale changes” to the MIPS (Merit-based Incentive Payment Program) under MACRA, as Rep. Price was a key player in the House around the MACRA legislation two years ago. But when it comes to the healthcare system reform aspects of the ACA itself, she said she believes that those provisions of the ACA are likely to stand.
Healthcare Informatics will continue to update readers on new developments in this evolving story.