There was an presidential communication regarding a potential change in Republican legislative strategy:
A statement by the President: pic.twitter.com/SnJXbXN8lT
— Real Press Sec. (@RealPressSecBot) June 30, 2017
How would this work?
The simple answer is that the House and Senate would pass updated versions of H.R. 3762, the Restoring Americans’ Healthcare Freedom
Reconciliation Act of 2015. And then President Trump would sign. Here is how the CBO describes it in January 2017:
would repeal portions of the Affordable Care Act (ACA)—eliminating, in two steps, the law’s mandate penalties and subsidies but leaving the ACA’s insurance market reforms in place. At that time, CBO and JCT offered a partial assessment of how H.R. 3762 would affect health insurance coverage, but they had not estimated the changes in coverage or premiums that would result from leaving the market reforms in place while repealing the mandate penalties and subsidies….
The number of people who are uninsured would increase by 18 million in the first new plan year following enactment of the bill. Later, after the elimination of the ACA’s expansion of Medicaid eligibility and of subsidies for insurance purchased through the ACA marketplaces, that number would increase to 27 million, and then to 32 million in 2026….
And then once there is a guarantee of 18 million more people being uninsured in the first year of implementation, Congress would pass a Replace bill. I think there is a presumption that Democrats would cave quickly and supply a significant number of votes for a very conservative bill in order to mitigate damage. It is a threat to shoot the hostage and then perhaps allow first aid to be administered.
There are several major mechanical problems with this idea. The most important one is money. Health care, as you may have noticed, is expensive. Covering people is expensive. And the first people to be covered are more likely to be more expensive than the last people to be covered. A repeal bill takes most of the current pay-fors (higher taxes) and burns them to the altar of Grover Norquist. A Replace bill would need to conform to Pay-Go rules which means every dollar on healthcare spending must be met by a combination of increasing taxes or offsetting cuts somewhere else in the budget. Replace in a Pay-go world is a major challenge for a party that is not allergic to raising taxes. It is an incredible challenge for a party that won’t raise taxes at all.
There is a far more important mechanical issue. There are not 218 votes in the House nor 50 in the Senate for a straight repeal without a replacement. As the CBO reported in January, the template Repeal bill would lead to 18 million people losing insurance in the first year and then 32 million by the end of the budget window. The AHCA and BCRA tempered those losses. Even with those tempered losses, these bills are polling at the same level of popularity as Nickelback. Democrats have an incredible club to beat Republicans on while motivating Democratic base voters for the mid terms now. That club gets even bigger on a Repeal only vote. That club does not go away if Replace is a multi-month legislative process that produces a massively underfunded bill that brings coverage losses down to “only” AHCA or BCRA levels.
I think that two-stepping Repeal and then never really replacing could have happened in the first three weeks of January in a mad rush to have legislation to be signed in the evening of January 20, 2017. But that ship has sailed.