While the public has long agreed with President-elect Donald Trump and congressional Republicans that the Affordable Care Act is badly flawed and requires major surgery, far more Americans believe the program should be kept but improved than repealed and replaced.
Shortly after Trump's stunning November 8 victory over Democrat Hillary Clinton – an ardent champion of Obamacare -- a Gallup poll found that while slightly more than half of Americans continued to express dissatisfaction with the program, 57 percent said they either wanted to keep the law as is or wanted to keep it and change the law significantly. Just 37 percent wanted to repeal and replace it as the Republicans have vowed to do.
Not surprisingly, views differ sharply between Republican and Democratic voters, reflecting the larger political divide throughout the country and in Washington. Seventy-one percent of Republicans told Gallup they disapprove of the law and want it repealed, while 59 percent of Democrats want to keep it with significant changes.
Taken together, the findings suggest a national unease among Americans over GOP leaders' determination to pass a budget resolution in the coming weeks that would repeal President Obama's signature national health insurance program that – for all its flaws – has provided coverage to more than 20 million Americans in recent years.
House Speaker Paul Ryan (R-WI) and Senate Majority Leader Mitch McConnell (R-KY) have joined Trump in denouncing Obamacare as irredeemable. They have vowed rapid legislative action in the coming weeks and months to repeal the law, even while the party is far from a consensus on replacement legislation.
"Obamacare is a disaster," Ryan said. "Insurance markets are collapsing. Premiums are soaring. Patients' choices are dwindling. The law has failed to deliver on its core promises, hurting far more than it is helping."
GOP leaders, for now, intend to repeal the program by the spring while setting the effective date a year or two down the road while Republican lawmakers hammer out a comprehensive alternative program that depends on more on market forces than government intervention and subsidies.
Yet that strategy is being met with opposition from insurers, hospitals and doctors, drug companies, consumer advocates and even many Republican governors who fear chaos and a collapse of Obamacare while the Republicans struggle to map out a new approach.
Just this week, the American Medical Association (AMA), the premier physician organization, wrote a letter to Republican leaders warning against jeopardizing the health care coverage of millions of Americans by abruptly repealing Obamacare without a suitable replacement. And Republican Gov. Rick Snyder of Michigan hailed the success of his state's expansion of Medicaid that was made possible by the Affordable Care Act.
A dozen moderate Democratic senators, including Tim Kaine of Virginia, Clinton's vice presidential running mate, wrote to the GOP leadership yesterday urging them to slow down and work with them to draft changes to the existing law to address concerns such as soaring premium and onerous taxes and mandates.
"There is so much we can immediately improve, but by pushing an immediate repeal through a partisan budget process, we won't have the opportunity to work together to build on that common ground," Kaine said, according to The New York Times.
G. William Hoagland, a vice president of the Bipartisan Policy Center and a former Senate Republican budget expert, said that the Republicans are still caught up in their campaign slogans and enthusiasm and aren't being pragmatic. However, reality will begin to set in when House and Senate committees begin stitching together the specific budget instructions to dismantle Obamacare, and many divisive issues rise to the surface, he said.
"Campaign rhetoric is one thing and legislating is another thing," Hoagland said in an interview Friday. "And I think the word 'repeal' is maybe being overused here by the Republicans – even before President-elect Trump is sworn in. What people are really talking about is amending the Affordable Care Act."
Hoagland, a health care policy expert, suggested that there is plenty of room for bipartisan compromise on changes to Obamacare, including adding Trump's proposals for lowering barriers to interstate sales of health insurance and the establishment of health care savings accounts. The biggest sticking point between Republicans and Democrats will be over how to subsidize health care costs for low-income Americans through the federal tax code and whether to make coverage mandatory or voluntary.
The Affordable Care Act mandates uninsured Americans to acquire coverage or pay the penalty. Ryan and others say their goal is to replace Obamacare with a law that guarantees "universal access" to health care coverage, but not necessarily to force everyone to be covered. Ryan yesterday declined to speculate on whether the 20 million or more Americans currently receiving coverage under the Affordable Care Act would continue to receive coverage under the GOP approach.
There is another obstacle for the Republicans in completely reinventing a national health insurance program: the cost. Blowing up Obamacare and starting from scratch would be a very costly enterprise. A complete repeal would include getting rid of a dozen major tax provisions that help underwrite the program's operating costs.
Before the election, the Congressional Budget Office projected that Obamacare operating costs would total $1.24 trillion between 2019 and 2026. There is compelling evidence that if the Republicans scrap all of the Obamacare taxes, they could raise at most $850 billion of the total required cost through a number of budgetary and tax policy maneuvers, according to a recent Brookings Institution analysis.
For these and other reasons, Hoagland says he could imagine a bipartisan deal next summer or fall that would retain the basic framework of Obamacare while layering in GOP provisions and innovations. He said that it would give Trump the opportunity to show off his legendary bargaining skills.
"The more I look at it . . . the more I sense that we're really talking about what you might call Trumpcare One or Trumpcare Two – Trumpcare modification of Obamacare," Hoagland said. "It just seems to me we're dealing with rhetoric right now and we're still in the campaign mode."