Ever since the election, the President and members of his party in Congress have been focused on one of the central promises nearly all of them made in their campaigns, to “repeal” Obamacare and – perhaps – to “replace” it as well.

Repealing and replacing Obamacare has proved as difficult to accomplish as passage of health reform was in the first place.  After all, it took President Obama about 15 months to get the Affordable Care Act (ACA) through Congress, and sign it, and to accomplish this he had to use nearly all the political capital he had, and even then it passed with literally no votes to spare when Obama had filibuster-proof majorities in the Senate and House.

Also, passage of national legislation to achieve anything close to universal coverage took about 100 years, since Teddy Roosevelt was the first President to advocate for universal coverage in the 1910s, and it took eight attempts at the national level before Obamacare passed.

But now that President Trump and the GOP have gained control of the Presidency and Congress, a political reality is kicking in.  That is, Trump and the GOP face a vicious Catch-22 as they attempt to write a health reform plan.  In particular Trump has said that "everybody's got to be covered", and that his plan will "take care of everybody" and that "government is going to pay for it" by providing "great plans, lots of competitions" that lowers costs.  So they have promised or have these goals:

  • Do not increase the uninsured;
  • Lower costs for private insurance plans;
  • Replace Medicaid expansion, and lower Medicaid costs;
  • Eliminate mandates, especially the “individual mandate”;
  • Strengthen private health insurance markets;
  • Keep insurance reforms (e.g., bans on existing conditions) and popular coverage expansions (e.g., adult dependents up to age 26), and
  • Eliminate tax increases enacted to pay for the ACA.
By now most if not all of the GOP members of Congress realize that achieving ALL of these goals is impossible.  For example, it is impossible to repeal the taxes enacted to pay for the ACA and have enough money left so that the same number of people are covered by insurance after passage of any reform legislation, since the subsidies in the ACA are what made it possible for the poor and near-poor to afford coverage. To cite another example, the stability of insurance markets will be severely strained if the mandate is repealed along with subsidies to buy coverage.

These are the huge policy dilemmas the GOP faces, the Policy-Catch-22.

But even beyond this, the POTUS and Congress face the dilemma of how to leave other provisions of the ACA intact – such as the closing of the so-called “doughnut hole” for Medicare recipients with prescription drug plans; the expansion of preventive coverage for Medicare; payment and delivery system reforms.

And these are just the daunting policy dilemmas, saying nothing of the political dilemma the GOP faces as it ponders replacing the ACA.  In particular, no matter what policy proposal they put forward, they can count on solid opposition from all or nearly all Democrats. Thus they need every GOP vote.  However, some members of the GOP are willing to repeal Obamacare without replacing it; some seek to scale back the ACA and limit it but not repeal it outright (e.g., Libertarians); some seek to fiercely protect provisions such as the expansion of Medicaid, especially if they represent a “red” state that expanded Medicaid (e.g., IN, AZ, NJ, OH); some balk at eliminating provisions such as expansions of preventive care for women.  

Leader McConnell can afford to lose only 2 votes, if he loses more votes he cannot pass legislation in the Senate, assuming he gains no Democratic votes. And he will need to garner 60 votes to even bring some parts of a “repeal and replace” legislation up for consideration, given the Senate filibuster rules. Although Speaker Ryan has control of more votes in the House, even he can only lose 24 votes (roughly 10% of the GOP caucus) before his 241-194 margin slips below a majority, and as Speaker Boehner will tell him the difficult “Freedom Caucus” is a bigger problem for him is a bigger problem for him than is a solid Democratic opposition.

In short, as President Trump recently said, health policy is “unbelievably complex subject.”  Indeed it is, as many of us knew.