Even as Republicans in the U.S. Senate and U.S. House of Representatives struggled to try to find unity in their efforts to “repeal and replace” the Affordable Care Act (ACA), sometimes referred to as “Obamacare,” President Donald Trump, in his first address to both houses of Congress since becoming President on Jan. 20, delivered a full-throated call for Congress to “repeal and replace Obamacare,” among other priorities he cited in his speech on Tuesday evening.
Addressing the members of both houses of the U.S. Congress, President Trump laid out a series of policy priorities, with the section of his speech devoted to the subject of the ACA coming about halfway through the speech. “Tonight, I am also calling on this Congress to repeal and replace Obamacare,” Trump said, “with reforms that expand choice, increase access, lower costs, and at the same time, provide better healthcare. Mandating every American to buy government-approved health insurance was never the right solution for our country. The way to make health insurance available to everyone is to lower the cost of health insurance, and that is what we are going to do.”
Trump continued, “Obamacare premiums nationwide have increased by double and triple digits. As an example,” he asserted, “Arizona went up 116 percent last year alone. Governor Matt Bevin of Kentucky just said Obamacare is failing in his state; it is unsustainable and collapsing. One-third of counties have only one insurer on the exchanges, leaving many Americans with no choice at all. There’s no choice left,” he said. “Remember when you were told that you could keep your doctor and keep your plan? We all know that those promises were broken. Obamacare is collapsing, and we must act decisively to protect all Americans.”
Trump said that four principles must guide the repeal and replacement of the ACA. “First, we should ensure that Americans with pre-existing conditions have access to coverage, and that we have a stable transition for Americans currently enrolled in the healthcare exchanges. Secondly, we should help Americans purchase their own coverage, through the use of tax credits and expanded health savings accounts—but it must be the plan they want, not the plan forced on them by the government. Thirdly,” he said, “we should give our state governors the resources and flexibility they need with Medicaid to make sure no one is left out. Fourth, we should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance — and work to bring down the artificially high price of drugs, and bring them down immediately. Finally,” he said, “the time has come to give Americans the freedom to purchase health insurance across state lines—creating a truly competitive national marketplace that will bring cost way down and provide far better care.”
Following the speech, a spokesperson for Sen. Lamar Alexander (R-Tenn.) released a statement that said, “The president’s speech was hopeful and well-delivered. I especially liked his focus on the importance of national defense, on restoring local control of schools, and on repairing the damage Obamacare has caused and replacing it with health care systems that provide Americans with more choices of health insurance at a lower cost.”
Meanwhile, some of the elements that Trump cited as necessary have been proposed for years, even decades, by congressional Republicans, including the idea that health insurance plans, an idea that is considered controversial by many, as it could lead to what some health insurance experts call a “race to the bottom,” as states that require adherence to more robust sets of regulations around health insurance, could be undermined by states with looser insurance product regulations.
In any case, efforts to move towards ACA repeal have become openly fraught with conflict from within the Republican ranks in both the Senate and the House of Representatives. “Republicans are having a break-the-glass moment on Obamacare,” wrote Burgess Everett and Jennifer Haberkorn, in a POLITICO article published Tuesday evening under the headline, “Republicans near make-or-break moment on Obamacare repeal.” “After promising for years to upend the Democratic health care law the first chance they got — and with plans to hold a vote to repeal by early April,” the reporters wrote, “the party remains far from consensus. So far, in fact, that Senate Majority Leader Mitch McConnell has called a special all-members caucus meeting Wednesday to try and get his rowdy caucus in line.”
As Everett and Jennifer Haberkorn said in their report, “Two key House committee chairmen running point on the House’s Obamacare efforts will be on hand to explain why Republicans should support their proposal to roll back Obamacare’s Medicaid expansion and replace insurance subsidies with tax credits, among other provisions. But a leaked blueprint of their plan is already taking heat from the GOP’s right flank, jeopardizing the repeal bid.” Meanwhile, they wrote, “In the Senate, Republicans can afford to lose only two of their members. But GOP leaders are facing pressure from both moderates and conservatives as they try to craft a bill. Centrists are signaling they won’t back a bill that rolls back Obamacare’s Medicaid expansion, which covers some 11 million Americans. But conservatives like Sens. Ted Cruz, Mike Lee and Rand Paul, as well as the House Freedom Caucus and outside conservative groups say they’ll oppose any measure that provides refundable tax credits to help people buy insurance—which is what the House’s emerging plan would do.”
Essentially, as Everett and Haberkorn made clear in their report Tuesday evening, there may not be enough unity either among Senate or House Republicans to craft and pass an ACA repeal bill that can please everyone across the Republican ideological spectrum. “In the Senate,” they wrote, “Republicans can afford to lose only two of their members. But GOP leaders are facing pressure from both moderates and conservatives as they try to craft a bill. Centrists are signaling they won’t back a bill that rolls back Obamacare’s Medicaid expansion, which covers some 11 million Americans. But conservatives like Sens. Ted Cruz, Mike Lee and Rand Paul, as well as the House Freedom Caucus and outside conservative groups say they’ll oppose any measure that provides refundable tax credits to help people buy insurance—which is what the House’s emerging plan would do.”
Political unity will be particularly important in the current congressional context, given that congressional Republicans have formally opened a process to use that any bill passed under the budget reconciliation process to repeal the ACA, and that process essentially requires any bill passed either to be completely budget-neutral, or alternatively, incorporate provisions that raise taxes or other revenues to support its content. Republicans have signaled their intention to eliminate both the individual and employer mandates around insurance purchase, among other provisions that could be difficult to execute on.
As noted in a report earlier on Tuesday, the draft bill that had been leaked to POLITICO on Feb. 24 focused solely on the health insurance provisions in the ACA, and made no reference whatsoever to the law’s internal health system reform provisions.
Healthcare Informatics will continue to update readers on this developing story.