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Tuesday Feb 14, 2017

Repairing ACA May be More Likely Than Full Repeal

This blog is brought to you by the letter R.  

No single letter better describes the first six weeks of the 115th Congress. "R" is, after all, for repeal, replace, reconciliation, repair, reform, restore, reduce, reservations, recording, retract, regulations, and -- most importantly -- reality.

As Congress and President Trump transition from campaign slogans to the hard process of legislating, it has become clear that promises made during the 2016 election to repeal the Patient Protection and Affordable Care Act "lock, stock, and barrel" are running headfirst into the reality of just how difficult such an endeavor is. I discussed the impact of a full repeal in a recent post.

The original plan outlined by Republican leadership after the election was to repeal the ACA prior to Trump's inauguration and then work during the next few years to develop and implement a replacement plan.  

Shortly after Congress convened in January, the House and Senate quickly passed a budget resolution that included
reconciliation instructions that would accelerate repeal. The resolution instructed five congressional committees to report their recommendations to the House and Senate Budget Committees by Jan. 27 -- a date that came and went with no apparent progress towards the development of repeal legislation.

In my Jan. 27 post, I predicted that the complexities of replacing the ACA would become the primary challenge. "Setting aside how complicated repealing the ACA will be, the complexity of that process pales in comparison to replacing the law," I wrote. This reality became apparent to members of Congress during a Jan. 25-27 meeting in Philadelphia.

After passing the budget resolution, House and Senate Republicans held their annual retreat where a number of members were heard expressing their reservations with the established "repeal and replace" plan. A significant number expressed their preference that a replace plan be drafted and vetted before they proceeded with a vote on repeal.  These reservations, which under normal circumstance would have been confidential, were shared with the world via a secret recording of the closed-door session. Shortly after the retreat, Republicans made a noticeable shift from "repeal and replace" to "repair."

Further complicating congressional legislative activities is an inconsistent message from the Trump Administration.  Trump has been consistent in his pursuit of full repeal of the ACA since the summer of 2015.  However, in an interview that aired on Super Bowl Sunday, he stated that work on the ACA may not occur until 2018.

The Administration still has control over the regulatory process and will, in all likelihood, make significant changes to the law through this process. This process will take time, lots of time, so this may be a contributing factor in the President's recent comments. It is way  too early to know if Trump's comments signal a shift in the Administration's priorities, but it certainly represents a change in expectations.

In the coming weeks, the five congressional committees (House: Ways & Means, Energy & Commerce, Education & Workforce; Senate: Finance, Health, Education, Labor, & Pensions) will develop legislative proposals to repeal the ACA. We anticipate that they also will begin work to develop a "skinny replace plan," which will allow them to signal their vision for a replacement policy at the time that they vote on repeal. It is unclear how quickly the House and Senate will move on repealing the ACA.

At this point, we anticipate votes in both Chambers prior to April 1, but timing is largely dependent on our final "R" in this equation, which is for Speaker Paul Ryan. At some point in the near future Ryan will need to identify a path forward and establish a reasonable time frame for legislative action.    

The AAFP continues to work closely with Congress and the Administration on health care reform. Our advocacy efforts are aimed at advancing priorities, which we outlined in a Nov. 9 letter to then President-elect Trump and then a Dec. 28 letter  to House and Senate leadership.  

We also continue to work closely with other physician organizations. On Feb. 2, AAFP President John Meigs, M.D., joined the presidents of the American College of Physicians, American Academy of Pediatrics, American College of Obstetricians & Gynecology, and the American Osteopathic Association in Washington, D.C., to meet with several senators. The five organizations advanced policies and recommendations that would ensure gains made in health care coverage, preserve existing patient-centered insurance reforms, and promote primary care as foundational to our health care system. AAFP News has a great summary of this collaboration and the Feb. 2 meetings.

The next few weeks will be pivotal -- primarily because the legislative clock is ticking. Although the legislative path forward is unknown, we do believe that both the House and Senate will take action on the ACA and health care reform more broadly. Whether they are successful depends on how you define success. I personally anticipate that "repair" will become the dominant "R" word in the coming days. 

In the infamous words of Dr. Dre -- "take a seat, I hope you’re ready for the next episode."

Comments:

Sean,

I think that you are dreaming and hoping that Obamacare will stay. The press is confusing the issue in hopes of keeping Obamacare.

Trump campaigned on getting rid of Obamacare and congress voted multiple times to repeal it while Obama was in office. The voters clearly wanted this when they elected Trump and a Republican majority congress. It would be political suicide to keep Obamacare.

It must go.

Posted by Solo in Indiana on February 14, 2017 at 01:49 PM CST #

You must have a newer model crystal ball than I have. When I ask, all that shows through the mists is "Please hold for further developments."

Posted by Peter J. Liepmann MD FAAFP on February 14, 2017 at 04:08 PM CST #

Shawn,

Sorry that misspelled your name. Nice Sesame Street reference. You must have young children at home.

Posted by Solo in Indiana on February 15, 2017 at 11:57 AM CST #

Shawn,

Great summary of the current "Rs" related to the ACA and health care reform environment in congress. At Ten State in Illinois this past weekend, you successfully outlined all the key influencers and specifically how AAFP continues to advocate for health equity and access for our patients to an audience full of leaders representing 10 AAFP state chapters.

Thank you for continuing to be our voice in DC and working hard on the Cs of Collaboration, Critical thinking, Common sense and Coverage for all!

Keep up the good fight!

Dr. Wil in Illinois

Posted by Dr. Wil in Illinois on February 19, 2017 at 12:41 PM CST #

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About the Author



Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.