Immediately after the election, Republicans and various pundits began writing the obituary for the Affordable Care Act. We were told that repeal would be accomplished within days of Trump’s inauguration with the caveat that repeal would take effect in two or three years while a suitable replacement was developed. Those plans are now colliding with reality as several Republicans realize that a repeal-and-delay strategy could sow chaos in the health care industry. Even President-elect Trump has gone on record saying that repeal and replacement should occur “essentially simultaneously.”
But this approach has its own problems. First, Republicans would need to agree on a replacement and that doesn’t seem imminent. Any GOP-backed plan is likely to cover far fewer people and offer fewer benefits, but Republicans don’t seem ready to admit this publicly yet. Also, a replacement would require 60 votes in the Senate, but Democrats don’t seem eager to play a supporting role in replacing a landmark piece of legislation for something demonstrably inferior.
So what happens next? Republicans may ultimately decide to proceed with repeal even if a replacement isn’t waiting in the wings. After promising repeal to their base for so long, they may feel that they have no choice but to fulfill their promise. Is this what the base really wants, though? Plenty of Trump supporters have purchased coverage through the exchange or they received coverage through the expansion of Medicaid. Their complaints regarding the ACA generally focus on the cost of coverage, not abstract notions of free-market principles. Issues of cost can be addressed through compromise, which could be entirely feasible in a saner political environment.
Governance is hard work and crafting health care policy is even harder, as Republicans are discovering. The ACA could certainly not be long for this world, but it has dodged fatal blows before. Perhaps it can defy death one more time.