The Future of Obamacare Looks Bleak

By Margot Sanger-Katz
November 9, 2016

Republicans in Congress have been calling for the repeal of Obamacare since it passed in 2010. With control of both houses of Congress and the presidency, they may finally get their chance to undo huge, consequential parts of the health law next year.

If they succeed, about 22 million fewer Americans would have health insurance, according to an estimate from the nonpartisan Congressional Budget Office.

Without a 60-vote supermajority in the Senate, Republicans can’t repeal the entire Affordable Care Act. But they can eliminate several consequential provisions through a special budgetary process called reconciliation.

We have a pretty good idea of what such legislation would look like. Last year, the Senate passed a reconciliation bill that undid large portions of the health bill. The House passed it. And President Obama vetoed it.

That bill, the “Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015,” would eliminate Obamacare programs to provide Medicaid coverage for Americans near or below the poverty line. It would eliminate subsidies to help middle-income Americans buy their own insurance on new marketplaces. It would eliminate tax penalties for the uninsured, meant to urge everyone to obtain health insurance. And it would eliminate a number of taxes created by the law to help fund those programs. (It was written to kick in after two years, meaning the programs wouldn’t disappear immediately.)

We don’t know, of course, exactly what legislation a new Congress would pass. And we can’t be sure that the vote would go down the same way a second time. But last year’s bill is a good template for what Republican leadership believes it can achieve through the special process. The Republican-led House has voted for dozens of total and partial Obamacare repeal bills. If we believe Donald J. Trump, who has vowed repeatedly to repeal Obamacare, he would seem likely to sign such a bill.

Many parts of Obamacare can’t be repealed through reconciliation. Among them: reforms to the Medicare program, a provision that requires insurers to cover young adults on their parents’ policies, and requirements that health insurers sell policies to anyone regardless of their health history. Those parts of the law are very likely to remain law.

The kind of partial repeal possible through the reconciliation process could lead to greater instability than total repeal. That means that it could lead to more people losing health insurance than the estimated 20 million who have gained it under the law. The health law was designed with a number of interdependent provisions devised to keep insurance affordable. By removing only some of them, a partial repeal could disrupt insurance arrangements not just for people newly insured under the law, but also for those who had purchased their own insurance before the law.

Republicans often talk about “repealing and replacing” the Affordable Care Act. But without a Senate supermajority, the replacement part may be politically impossible. Making the kind of legislative changes to stabilize disrupted markets — or to enact the kind of broader health care reform Mr. Trump has spoken about on the campaign trail — will require 60 votes in the Senate. Without those votes, the new Republican government will have the power to repeal substantial parts of the health law, but it may not be able to replace them.