A big question facing Republicans next year is how to pass a national healthcare reform law without taking a beating on Election Day.

Obamacare has been implemented, and 20 million Americans have health insurance through the law. That means Republicans have to figure out how they will keep their promise to repeal Obamacare without angering the people who already receive coverage from the law.

It’s a critical question for the GOP, as a matter of policy and politics, and they know from beating Democrats across the country how an unpopular healthcare bill can poison a lawmaker’s re-election chances.

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The worm is about to turn in health policy and politics when Republicans shift from throwing stones to owning the problems of the health system and the Affordable Care Act or its replacement, as President Barack Obama and Democrats have for the past eight years. It’s hard to predict how events will play out, but it’s likely that grand plans to repeal and replace Obamacare, convert Medicaid to a “block grant” program, and transform Medicare into a premium support program could be whittled down or delayed as details of such sweeping changes, and their consequences, become part of the debate.

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 Repealing Obamacare will be the first priority of congressional Republicans when Donald Trump takes office in January, House Speaker Paul Ryan told CBS’s “60 Minutes.” “Well, the first bill we’re going to be working on is our Obamacare legislation,” he said in an interview airing Sunday night, though he declined to offer a timetable. “We want to make sure that we have a good transition period, so that people can get better coverage at a better price.” When pressed by anchor Scott Pelley, who asked about a three-year transition, Ryan said, “I don’t know the answer to that right now. What we know is we have to make good on this promise. We have to bring relief as fast as possible to people who are struggling under Obamacare.”

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Incoming Health and Human Services Secretary Tom Price is now assisted, instead of annoyed, by the big, executive powers granted by Obamacare.

As Price takes the helm at HHS, he will succeed Obama appointees he had sharply criticized for taking wide latitude in implementing the Affordable Care Act.

Now that the tables have turned, and Republicans hold the White House, Price will have the ability to reverse, rewrite or do away with dozens of rules and guidance spelling out exactly how individuals, businesses, health providers, insurers and states should comply with the healthcare law’s many requirements.

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Republicans are pitching Obamacare “repeal and delay”—the idea of quickly repealing the ACA, but leaving it in place for three years as they craft a replacement. But one key health care expert threw cold water on that idea. Robert Laszewski, president of Health Policy and Strategy Associates, warned the strategy could send the market into “death throes.”  He argues that to stabilize the insurance market and ensure that health insurers don’t flee is for the federal government to guarantee to cover their losses. But the politics of that aren’t easy because it would mean funding the three R’s— (risk adjustment, reinsurance, and risk corridors, all programs that subsidize insurance carriers that have significant losses.)

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Republicans on Capitol Hill are grappling with the likelihood that they will need Democratic support to pass parts of any plan replacing the Affordable Care Act, setting up a complex legislative battle over the law’s future.

President-elect Donald Trump is expected in his first days in office to take executive action voiding parts of the health law that the administration has discretion to change. Soon after that, lawmakers likely would start on their efforts to repeal and replace the law.

With full control of Congress and the White House, Republicans have anticipated being able to repeal the law using a special budget maneuver that would allow them to get around a filibuster by Democrats in the Senate.

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Congressional Republicans are setting up their own, self-imposed deadline to make good on their vow to replace the Affordable Care Act. With buy-in from Donald Trump’s transition team, GOP leaders on both sides of the Capitol are coalescing around a plan to vote to repeal the law in early 2017 — but delay the effective date for that repeal for as long as three years.

“We’re talking about a three-year transition now that we actually have a president who’s likely to sign the repeal into the law. People are being, understandably cautious, to make sure nobody’s dropped through the cracks,” said Senate Majority Whip John Cornyn (R-Texas).

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House and Senate budget leaders are teeing up a vote to repeal most of ObamaCare by Jan. 20, 2017, according to multiple sources. The leaders of the House and Senate Budget committees are planning the vote for the first week of January, to deal an immediate blow to ObamaCare after President-elect Donald Trump’s inauguration, according to a Senate GOP aide. Another source off Capitol Hill said the Trump transition team has signed off on the plan and that the traditional vote-a-rama process could take place as early as Jan. 5.
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The new direction of American health care should be fully consumer driven, empowering individuals to be the surveyors and purchasers of their care. If President-elect Trump and Rep. Tom Price, Trump’s HHS pick, want to make the most of this short window, they should keep four central reforms in mind: 1) Provide a path to catastrophic health insurance for all Americans. 2) Accommodate people with pre-existing health conditions. 3) Allow broad access to health-savings accounts. 4) Deregulate the market for medical services.

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Price is of the view that we are going to end up subsidizing the health care of the poor and the indigent one way or the other. We can do it through cost shifting and subsidies conferred on impersonal hospital bureaucracies or we can give the money to the people and let the bureaucracies compete for their patronage. The Price tax credit would be refundable and it would vary by age. But unlike the Obamacare credits, Price’s credit would be the same, regardless of income.

That last feature is huge. The most important reason why the exchanges have been so dysfunctional is the need to verify income.

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