Lamar Alexander: Obamacare repeal and replace effort could take years

Earlier today Ed wrote about Senator John Cornyn’s suggestion that a bill to repeal Obamacare could be ready on day one of the Trump administration. But Senator Lamar Alexander said today that a full repeal and replace could take years to accomplish. From the Hill:

“I imagine [it] will take several years to completely make that sort of transition to make sure we do no harm, create a good healthcare system that everyone has access to and we repeal the parts of ObamaCare that need to be repealed,” the Tennessee Republican told reporters on Thursday…

“Eventually, we’ll need 60 votes to complete the process of replacing ObamaCare and repealing it because ObamaCare was not passed by reconciliation; it was passed by 60 votes. And it was cleaned up by reconciliation because Scott Brown won his election,” he said.

This gets to a disagreement over not just when to repeal and replace Obamacare but how it can be done. In Sen. Cornyn’s remarks earlier in the day he was talking about using reconciliation to repeal it, a move which would only require 51 votes. However, because of the unusual way in which Obamacare was passed, some observers believe reconciliation can only upend the portion of Obamacare that was passed by reconciliation in 2010. Last week, Avik Roy described what that partial repeal would look like:

The best that Republicans can do is to pass a partial repeal of Obamacare using the reconciliation process, which only requires 51 votes. Republicans did this in January, when they sent to President Obama’s desk the Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015.

That bill would have repealed Obamacare’s tax hikes, Medicaid expansion, and insurance exchange subsidies, affecting more than 15 million enrollees. That’s a big deal, because it affects $2 trillion of spending over the next decade.

But critically, the partial repeal bill does not get rid of Obamacare’s tens of thousands of pages of insurance regulations, the regulations that are responsible for the law’s drastic premium hikes.

Since the bulk of Obamacare was passed earlier in December 2009, back when Democrats still had 60 votes, that may need to be repealed the same way. That’s why Sen. Alexander is suggesting that a full repeal is only possibly with 60 votes.  And since, at present, Republicans don’t have 60 votes in the Senate, a repeal anytime soon would require Democratic support.

However, there is an ongoing disagreement about how much of repeal could be accomplished using reconciliation. The Heritage Foundation has argued that it is possible to repeal the law with 51 votes. In a piece at Politico last week Brian Blase and Paul Winfree made the case:

The main problem with last year’s reconciliation bill is that it maintained the ACA’s insurance market regulations. These include the rules that all insurance meet or exceed Washington-dictated standards for what benefits they cover, as well as pricing rules that substantially raised the price of insurance for younger and healthier people. These rules have resulted in ACA plans proving attractive only to people who qualify for large taxpayer-funded subsidies and have led many to wait until they need medical care to purchase coverage.

The repeal effort therefore must address these insurance market regulations. One way would be to include the repeal of those regulations in the reconciliation bill. The reason they were not included in the first place is because all provisions of a reconciliation bill must have a nontangential budgetary impact. Congress chose not to litigate that issue with the Senate parliamentarian last year. But it is clear that those rules are inseparable from the rest of the ACA’s structure. In fact, the Obama administration argued this before the Supreme Court in King v. Burwell, the case over whether enrollees who buy insurance through the federal exchange are eligible for subsidies. As a result, Congress may repeal those regulations via reconciliation.

Even a reconciliation bill to repeal all of the ACA would only be a start to the whole process. The replace part of the plan will require Republicans to actually draft a bill, something which will take months. The GOP definitely does not want to create a total disruption in the marketplace without laying all the groundwork for their alternative solution.

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