Over the course of nearly six years, Republicans have passed dozens of bills to repeal all or part of Obamacare, but they have always been stymied — first by a Democratic Senate and then by President Obama. As frustrating as this was to conservatives, this reality also came with a political benefit to the GOP: because Republicans knew their moves would eventually be blocked, they were able to tout their efforts to repeal Obamacare without having to deal with the consequences, or wrestle with the hard work of unifying the party around an alternative.

With the election of Donald Trump and retention of both chambers of Congress, all of that has changed. Republicans now have the power to wipe Obamacare off the books and their base will expect them to finally deliver. But that means they’ll also have to deal with the consequences. The question facing the party over the next few months is: Do they have the will?

The road from Tuesday’s election to repealing and replacing Obamacare is a long and arduous one that neither Republicans nor Trump are prepared for. Repealing the bill outright without replacing it with anything raises a number of political issues for Republicans. But waiting for Republicans to agree on a plan to replace the law would significantly delay the repeal effort.

Because Republicans do not have a filibuster-proof majority of 60 votes in the Senate, they’ll have to use a complex legislative maneuver known as reconciliation to allow them to repeal much of the law with a simple 51-vote majority. A number of people mistakenly believe that Obamacare itself was fully passed via reconciliation. The reality is a bit more complicated.* We’ll have plenty of time to get into the weeds of reconciliation in the months to come, but for now it’s worth keeping in mind that it’s a messy process, and that not all of the law could be repealed this way. You could get rid of the taxes and spending provisions (which does constitute the core of the law), but you couldn’t attack the regulatory regime that way. That said, through a combination of reconciliation and regulatory action by Trump’s secretary of Health and Human Services, Republicans could effectively repeal nearly all of Obamacare.

Should they repeal it outright, however, there would be a number of consequences. There are already about 20 million people receiving coverage through Obamacare — either through its insurance exchanges or Medicaid. To put it in context, that number is higher than the record number of people who voted for Trump in the Republican primaries and it is roughly equal to the population of his home state of New York. Democrats, and the media, will highlight all of the most sympathetic stories of those standing to lose coverage, particularly those with pre-existing conditions. Republicans, who spent years hammering Obama on his broken “if you like your plan, you can keep it” pledge and railing against unaffordable insurance will have to be willing to explain why so many people would be losing their plans. It’s unclear whether they would have the stomach for that fight.

Fully repealing the law without simultaneously replacing it would also complicate the budget math. The reason is that as long as Obamacare is on the books, any plan to replace the law is judged relative to Obamacare. That means if Republicans want to, say, offer tax credits toward the purchase of insurance, it could be deemed a spending cut, because they’d simultaneously be saving trillions of dollars by slashing Medicaid and Obamacare exchange subsidies. But if they wipe Obamacare off the books first, and then try to replace the law, any spending – on tax credits, on addressing those with pre-existing conditions, and so forth – would count as a spending hike.

So, they’d ideally want to replace the law as they repeal it. The problem is, despite the urgings of people such as myself and others for years, Republicans have not resolved their differences over healthcare policy and united around an alternative. Back in early 2015, I released a book that detailed three different schools of thought on the right about how to replace Obamacare with a market-friendly alternative. When writing the book, I expected it to presage the big fight over healthcare that was going to play out in the Republican presidential primaries.

As it turned out, there were only three GOP candidates that released what could really be described as healthcare proposals during the primaries – Gov. Scott Walker, Bobby Jindal and Jeb Bush. Two of those candidates never made it to Iowa, and Bush didn’t last very long either. As Trump sucked all the oxygen out of the room, Republicans didn’t litigate the key policy differences concerning healthcare. This prompted me to write, last November, “Obamacare is imploding and Republicans are unprepared.” Well, they still aren’t prepared. The core problem still exists – though there are many ideas for such an alternative, Republicans haven’t settled on a single one. The one that the House Republican leadership released only represented one type of Obamacare alternative. (For more on the areas of disagreement, see my book, or read this post on the biggest obstacles for Republicans agreeing on an alternative.)

Remember, after the stimulus passed in February 2009, the Obama White House and Democratic Congress (with larger majorities than the incoming GOP class) put all of their energies into writing and passing Obamacare. They were further along, and had a president whose primary focus was to achieve the domestic policy goal that had eluded liberals for more than a half century. And it took them 13 months to get it signed into law. So, the problem with waiting until a replacement is negotiated to pass repeal is that it could delay repeal indefinitely. And by that time, Trump’s honeymoon period (already likely to be the shortest since Abe Lincoln) would be over, Republicans may start worrying about 2018, and the whole effort could collapse. In other words, by tying together repeal and replace, Republicans risk getting neither.

O'Malley taking 'hard look' at DNC chair run

Also from the Washington Examiner

Former Maryland Gov. Martin O’Malley revealed Friday that he is taking a “hard look” at a run for chairman of the Democratic National Committee in March, when a new chairman will likely be voted on.

In a statement, O’Malley said he has been approached by members of the party about a possible run and will look into a bid for the chairmanship, citing the need to reform the party’s nominating process and to return the organization to a more “grassroots” party.

“Since the election, I have been approached by many Democrats who believe our party needs new leadership,” O’Malley said.

11/11/16 11:07 AM

Another option, as outlined by my colleague Paige Winfield Cunningham, is that Republicans could pass a “budget reconciliation bill that gradually sunsets the law, preserving its subsidies and Medicaid expansion for a time while they agree on a replacement.” Such an approach sounds feasible in theory, but in practice, it would present a number of policy and political issues. Politically, there would be pressure from conservative groups, suspicious of Congressional Republicans, who would fear that if repeal were delayed, that it wouldn’t happen. Also, what if the law hasn’t fully sunset by the 2018 midterms, and then Democrats take over Congress, and try to rescue the law?

Policy wise, it also isn’t clear how that would work. Sunsetting the law wouldn’t solve any of the immediate problems facing the law that are causing premiums to spike. Also, insurers have to make decisions about whether or not to participate on Obamacare well in advance. The only reason that any insurers are still participating in Obamacare despite losing money is out of the hope that if they stick with it, and the program survives and stabilizes, then it will be a steady source of income in the future. If Republicans come in and say, “we’re going to repeal it and replace it with something else,” why would insurers participate in the program in the meantime, and expose themselves (and their investors) to hundreds of million dollars of losses with no hope that it will benefit them down the road?

To be clear, none of this is to discourage Republicans from repealing and replacing Obamacare – I’ve spent more time in the past decade of my life writing about the need for market-based healthcare and the dangers of Obamacare than I have about anything else. I strongly hope they succeed. This is just to point out that it is no guarantee that it will happen. It’s going to take will, persistence, hard work, time, focus, dedication, a willingness to take short-term political risks, and likely putting other domestic policy priorities on the back burner. Are Republicans up for it?

* In late 2009, Democrats passed two different versions of Obamacare – one in the House, and one in the Senate. The Senate version did pass with 60 votes in December. The thought was, once they got back from the holidays, House and Senate Democrats would hash out their differences, and then put together a final bill that would pass both chambers. But then in January, when Scott Brown won a surprise victory in the Massachusetts special election to replace Ted Kennedy, they dropped to 59 votes. To secure final passage, the House agreed to pass the original Senate bill, but only if the Senate agreed to pass a separate bill that included some negotiated changes. And its that separate bill that passed through reconciliation. So, while it would be accurate to say that Democrats used reconciliation to secure final passage of Obamacare, it isn’t accurate to say the entire law was passed through the reconciliation process.

Noonan to Trump's GOP critics: 'Help him'

Also from the Washington Examiner

She said the Trump administration would be smart to welcome old Washington hands.

11/11/16 10:45 AM

Five things Trump could do to change Obamacare right away

Top Story

There’s a laundry list of things President-elect Donald Trump could do on his own to modify the Affordable Care Act, even if Congress gets hung up on exactly how to repeal and replace it.

While the Affordable Care Act is a lengthy piece of legislation, the Obama administration issued many more pages of regulations and guidance explaining exactly how it should be implemented. The new administration, under the direction of Trump, could amend or get rid of those directives as soon as it’s in place next year, and thus significantly alter the law without having to wait for Congress.

Additionally, the Department of Justice is involved in several ongoing disputes involving the healthcare law and some of the payments it lays out for

11/11/16 12:01 AM

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