Will Obamacare be repealed? If so, what then?

A version of the following originally appeared on The Upshot (copyright 2016, The New York Times Company). It also appeared on page A3 of The New York Times print edition on November 22, 2016.

The election of Donald J. Trump gives the Republicans in Congress a chance to act on their often-stated desire to get rid of Obamacare, a wish that Mr. Trump mostly says he shares. Aaron E. Carroll and Austin Frakt, our health policy columnists, discuss: Then what?

Aaron: I think it’s safe to say few in Congress thought they’d have this opportunity. But like the proverbial dog who has finally caught the car, after untold futile attempts, Republicans have finally come within reach of repealing the Affordable Care Act. Now comes the essential question: Will they actually do it? They’ve been promising it forever, but I am still skeptical that it will happen. I believe you disagree. I’m going to let you go first. Why do you think they’ll do it?

Austin: I think they’ll do it because they so thoroughly own the idea of repeal, having passed bills to repeal, partly repeal, delay or defund the A.C.A. in the House something like 60 times. Just the other day Senator Mitch McConnell endorsed repeal (again). The House and Senate also agreed to do so, in large part, in a budget reconciliation bill earlier this year. The only thing that prevented it was that President Obama vetoed it. I doubt Mr. Trump would do the same if given a similar opportunity.

Now, I know that a budget reconciliation dismantling of the law is not a full repeal, because according to the rules it can only touch budget-related provisions. This excludes things like requiring insurers to take all comers for premiums that vary only by age and smoking status or preventing them from imposing coverage caps and lifetime limits, among other measures.

I also must add that I’m much less confident of a repeal (or partial repeal) without agreement on a replacement. But I’ll turn it back to you, Aaron. Do you think the G.O.P. has to offer a full replacement to get its members to sign on to repeal? Or can it offer something that would cover fewer people and with fewer benefits?

Aaron: I think they can get away with slightly fewer people and somewhat skimpier benefits, but not too much. There’s a part of me that thinks many in Congress were always so willing to vote for a “repeal” because they knew it had no chance of being signed into law. They got credit for the vote without ever having to face the downside. Actually repealing without replacing would mean effectively stripping more than 20 million people of their health insurance, without anything in return.

This would be an unmitigated political disaster. The stories — of people with cancer, diabetes and more who were suddenly stripped of their insurance and left out in the cold — would very likely dominate our discussion for months. That leaves more than enough time to lead to significant repercussions in the 2018 midterm elections. With no Democratic leaders in any branch of government to blame, I think this would be akin to what happened in the 2010 elections, but in reverse.

Now, if they can coalesce around a “replace” plan that doesn’t leave too many people out, then I think they could move forward. But in all the years since the A.C.A. was passed, Republicans haven’t been able to do that. Do you think they can? What do you think that plan would look like?

Austin: One way to get from repeal to replace that minimizes immediate downside political risk is to pass a plan that doesn’t call for repeal for several years, at least after the 2018 midterms, though possibly after the 2020 election. Between now and then, there would need to be some kind of transition to whatever replaces Obamacare that didn’t just dump people off coverage with no alternative.

But the alternatives could just be not as comprehensive or costly. Absolutely there will be bad stories. But keep in mind, there will be bad stories under Obamacare, too. Rocketing premiums, huge cost sharing and markets with few choices is not a recipe for political success. Republicans now own the task of fixing those things and doing so in a way that does not look as if they’re making Obamacare better.

They’re actually in a tough policy spot. They’ll get the blame if they don’t fix or repeal the A.C.A., and they’ll get the blame if they don’t replace it with something people like better. Health policy is a very difficult and thankless task. I think they’ll opt for something they can call repeal and replace, but they could also just let Obamacare struggle and die. Neither looks good.

One other way to get out from under the issue is to kick it to the states. Do you think a Trump administration, working with a G.O.P. Congress, will offer greater flexibility to states to design their own coverage plans that could diverge from Obamacare? If so, what are some ideas states might try?

Aaron: I think it’s very likely those in Congress could punt Medicaid to the states. For years, they’ve been trying to change Medicaid funding to a block grant that they can then constrain over time. This will be enticing for them because it will allow them to reduce Medicaid spending in the future, while forcing states to make the tough decisions — and take the blame — for cuts in either beneficiaries or services.

Fixing the markets for those who are getting health insurance through the Obamacare exchanges, though, is a different story. Without some sort of market regulation, which they’ve generally been opposed to, the same problems that existed pre-A.C.A. with respect to pre-existing conditions and individual ratings will exist. Many people will become uninsured. Annual and lifetime limits could reappear. Lots of people will have problems getting insured.

Moreover, I have yet to be convinced that a significant number of Republicans in the House might coalesce around such a plan. Maybe for Medicaid, but I’m not sure about the exchanges. Even if they could, it’s likely the Democrats in the Senate would try to filibuster either of these plans. Don’t you think?

Austin: Yes, I think Democrats would filibuster anything they could. The filibuster is not set in stone. A Senate majority can change it, and some are already calling for the G.O.P. to do so. But that doesn’t appearto be what the Senate will do — they’ll retain the filibuster. This could play to their favor, since they can propose things they like, let the Democrats filibuster them and take the blame when repeal kicks in with no replacement. Perhaps that’s another way for Republicans to get out of their political bind.

Aaron: I’m sure we’ll have more to discuss as President Trump’s administration comes into power.

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