Unable to kill the Affordable Care Act, Republicans may now have to fix it.
The White House and even GOP members of Congress risk a huge political backlash if they allow the healthcare law to come apart, as President Trump has predicted it will.
That leaves Republicans with a strong incentive to take steps to shore up Obamacare insurance markets, keep premiums in check and preserve consumer protections in a way that would be acceptable to both sides of the aisle in Congress.
“This may finally provide an opportunity to do this in a better way,” said G. William Hoagland, a former Senate Republican budget official who is now senior vice president at the Bipartisan Policy Center. “The only way to make something sustainable is if Republicans and Democrats work together.”
In fact, some of the Republicans whose resistance led to the collapse of the House bill had already said they were concerned that repealing Obamacare would leave their constituents with worse health coverage or none at all.
It’s unlikely any changes will happen immediately, given partisan tensions in Washington. And the Trump administration could easily make important parts of the healthcare law implode, if the president chooses that path.
But, as former Senate Majority Leader Tom Daschle, a longtime advisor to President Obama, noted: “The fact is, both parties own this now.”
That means Trump soon could find himself in the same position as previous Republican presidents who criticized government healthcare programs only to end up strengthening them in the end.
President Reagan implemented revolutionary changes that expanded Medicare’s power over hospitals, for example. And President George W. Bush pushed through another historic expansion of Medicare by creating the Part D drug benefit.
“What we need to do now is put our heads together and figure out how to make things work,” said Dr. J. Mario Molina, head of California-based insurer Molina Healthcare. “I think the American people would support that.”
On Capitol Hill, several senior Senate Republicans have been working privately on measures to help consumers in parts of the country where insurance premiums have surged in the last year.
And Democratic senators in states that Trump won in November have signaled willingness to work on bipartisan fixes to Obamacare.
“Republicans have a new opportunity to work with us to bring down the cost of premiums and co-pays for insurance, lower the cost of prescription drugs and make it easier and less expensive for our small businesses to provide healthcare to their employees,” Sen. Debbie Stabenow (D-Mich.) said after the House vote Friday.
On the GOP side, Tennessee Sen. Bob Corker said Friday he is “ready to work with the administration and my colleagues on both sides of the aisle.”
Tennessee has seen some of the largest premium increases this year. In several parts of the state, there may be no insurers selling health plans next year following insurance giant Humana’s decision to leave the market.
Following the November election, Tennessee’s other senator, Republican Lamar Alexander, who chairs the Senate health committee, began exploring interim steps to fix the markets that stopped short of repealing Obamacare.
That would be welcome, said former Tennessee Justice Center director Gordon Bonnyman, a leading liberal activist in the state.
“Anyone who has worked with the Affordable Care Act would say there are lots of problems and lots of room for improvement,” he said. “If the point of this exercise is to help people, there ought to be plenty of space to meet in the middle.”
To be sure, the collapse of the House effort to roll back the healthcare law doesn’t mean the Trump administration and congressional Republicans and Democrats will suddenly work harmoniously together.
Feelings on both sides remain raw. Many Democrats aren’t in the mood to help a president they increasingly view as illegitimate and dangerous.
And Friday, Trump tried repeatedly to blame Democrats in the aftermath of the repeal effort’s defeat.
At the same time, the administration is stocked with officials deeply hostile to Obamacare, most notably Health and Human Services Secretary Tom Price.
Former Utah Gov. Mike Leavitt, a Republican who served as Health secretary in the last Bush administration, cautioned that GOP interest in changing the law has hardly evaporated. “Today, we are left in a place where they will have to do it incrementally,” he said.
Price could easily use his regulatory authority to undermine key parts of the law, such as the insurance marketplaces that serve about 10 million Americans who don’t get coverage through an employer.
Millions of low-income consumers in the marketplaces depend on federal aid that offsets not only their monthly premiums but also the out-of-pocket costs that many health plans require, such as deductibles and co-pays. Under current law, the administration could stop assistance for those out-of-pocket costs.
Taking away that aid would be hugely disruptive, many insurance industry officials believe.
Insurance officials also are worried that the Trump administration may not enforce the current insurance mandate, which is supposed to penalize people who do not have insurance. “We need that,” Molina said.
Stabilizing the insurance markets, however, would not be very difficult, according to many experts, despite the large price increases in some parts of the country.
“The fixes are pretty straightforward,” said Manatt Health managing director Joel Ario, a former insurance commissioner in Oregon and Pennsylvania.
The Trump administration already has shown a willingness to do some.
In February, for example, the Health and Human Services Department issued regulations to restrict when people could sign up for health plans.
Insurers have complained that too many customers have been waiting until they are sick to enroll in coverage and then dropping the coverage after they no longer need medical care.
Ironically, the House bill that just collapsed included another tool that insurance experts say is key to sustaining markets. That tool, which already is used in Medicare, offers additional financial assistance to insurers that have unexpectedly high-cost patients.
Some of the steps needed to stabilize insurance markets probably would require action by Congress.
But with several key healthcare bills due to come up later this year — including legislation to reauthorize the popular Children’s Health Insurance Program — Republicans and Democrats will have many opportunities.
“I don’t think that we are done talking about this,” Leavitt said.
6:10 p.m.: Updated to include additional context and background.
This story was originally published at 1:55 p.m.