The messy politics of repealing Obamacare

Donald Trump and Republicans are about to encounter a political nightmare: unraveling Obamacare.

Already there are tensions between Trump, who’s been shaky on the specifics of the 2010 health care law and says he wants to keep the popular parts, and congressional leaders like House Speaker Paul Ryan and conservative think tanks who ideologically, almost theologically, oppose anything associated with the Affordable Care Act.

They’re going to get squeezed in a political vise. The Republican base demands that the act be repealed, but most voters have more nuanced ideas. Polls consistently show that while a plurality of voters disapproves of the law, big majorities want to keep some provisions and care more about issues like rising drug prices.

While candidate Trump vowed to repeal the law, he also said he’d like to see Medicare negotiate lower drug prices and bring in cheaper drugs from Canada, positions opposed by most congressional Republicans and the drug industry. The president-elect now says he wants to keep important elements of Obamacare, including a ban on insurance companies discriminating against people with preexisting medical conditions and another allowing children to stay on their parents’ plans until age 26.

There’s a reason Republicans have voted to repeal Obamacare scores of times but have not, in 6 1/2 years, devised a coherent replacement: It’s tough substantively, and treacherous politically.

The best policy and politics would be to fix parts of the law that have produced big recent increases in the cost of premiums for the sliver of Americans who don’t get insurance through Medicare, Medicaid or their employers, and don’t qualify for subsidies through Obamacare. Some cutbacks and additional cost controls would also be useful. But the Republican base would never accept those measures, meaning the likely course will be to craft a radical replacement.

Then, a year or two from now, the headlines wouldn’t be about rising premiums or not being able to keep your own doctor. They’d be about some of the 20 million newly insured people being thrown off the rolls, Medicaid cutbacks for poorer Americans, crowded emergency rooms, weakening of provisions that are reducing hospital-caused patient harms, maybe some hospitals going broke, and the insurance industry in chaos. That picture would not sit well with a lot of the working-class voters who backed Trump.

It would be one of the many lessons inflicted upon the new president. Going back to the early 1990s, the politics of health care has repeatedly changed. Democrat Bill Clinton was elected president by promising to reform the system. His plan failed, giving Republicans a boost on their way to taking control of the House in 1994. The next pendulum swing helped President Barack Obama get elected in 2000, only to see the result become a successful issue for Republicans.

Now it’s their turn to feel the heat again.

This story was originally published November 20, 2016 at 5:15 AM with the headline "The messy politics of repealing Obamacare."