The ongoing debate over soon-to-expire Affordable Care Act insurance subsidies has reopened an old wound for Republicans: What should they do about the health care law they have railed against for more than a decade but has now taken root with their own constituents?
While some GOP hard-liners are again embracing repeal-and-replace rhetoric, the scars from the party’s failed attempt to undo the ACA in 2017 have left a broader swath of Republicans extremely wary of trying to rip out the law — even as they continue to criticize it.
Instead, as Democrats put the ACA at the center of the ongoing government shutdown fight, Republican leaders and key senators are acknowledging the political reality that Obamacare, at least for the immediate future, is here to stay. Republicans are, instead, eyeing a bipartisan end-of-year health care push that could pair a conservative overhaul of the expiring subsidies with modest proposals that would tweak — but not fully uproot — the 2010 law.
Speaker Mike Johnson is downplaying prospects for nixing the ACA ahead of the midterms, saying this week he still has “PTSD” from the GOP’s 2017 repeal-and-replace debacle.
Senate Majority Leader John Thune made clear in an interview his members are making plans for a bigger health policy push, including “reforms” to the subsidies, in the next government funding package and potentially elsewhere before the end of the year.
“There’s some very interesting potential health care discussions and even solutions out there, and obviously reforms that need to be made to the Obamacare enhanced subsidies,” Thune said, adding that a bipartisan agreement could move as part of a “broader package” or “independently” after the shutdown ends.
The expiring tax credits, expanded by Democrats in 2021, are driving the desire to act on health care this year — millions could go uninsured come the new year without legislative action, according to the Congressional Budget Office. At the same time, Republicans have been discussing a menu of other options in the health care policy arena, both among themselves and with White House officials.
Ideas include overhauling the operation of drug intermediaries, known as pharmacy benefit managers; granting Americans additional options around Health Savings Accounts; and allowing more flexible employer-provided health insurance plans.
“Our members have been working on plans to reduce premiums for families for months now,“ House Majority Leader Steve Scalise said in an interview, mentioning HSAs and “things that are focused on reducing premiums.” But, he added, Republicans haven’t yet worked out how to bring those proposals to the floor.
Another big question is how much buy-in from Democrats those proposals might have. Republicans appear unlikely at this point to pursue a party-line reconciliation bill that would include health care policies — at one point a possibility following the success of the tax and spending megabill passed over the summer — which means some bipartisan support will be necessary to get any legislation passed in the Senate.
Senate Finance Committee Chair Mike Crapo said in a brief interview that Senate Republicans have been discussing a year-end health care package, including on HSA flexibility, and “my hope is to have it be bipartisan.”
Asked about the possibility of linking that to a potential extension of the ACA tax credits, he said, “If we have a vehicle that’s moving, I see no reason not to add it.”
But Democrats are already seizing on the repeal talk in some corners of the GOP, with Sen. Patty Murray of Washington comparing it to the cataclysmic sinking of the Titanic.
“It is bad enough so many of them can see the iceberg coming and are saying, ‘Ah, we’ll worry about that after the ship goes down.’ But we’ve also got Republicans saying that you wish this ship had sunk earlier,” Murray, the Senate’s top Democratic appropriator, told reporters. She was referring to the GOP’s refusal to extend the Obamacare subsidies before Nov. 1, at which point notices will go out alerting enrollees to massive premium hikes.
One favorite GOP proposal, known as a “CHOICE arrangement,” would allow employers to reimburse employees on a tax-free basis for health insurance premiums or medical expenses. It was one of several health policies that passed the House as part of the GOP megabill but didn’t get enacted in the final product.
House Republicans have indicated that there is appetite to revisit dropped policies such as this one, but a senior House Republican aide who works in health policy, granted anonymity to speak candidly, said it wouldn’t be enough to satisfy hard-liners.
“I don’t see an extension of the Obamacare subsidies happening without a bunch of reforms alongside conservative health care policy wins, and CHOICE arrangements alone is not enough,” the aide said. “That’s not getting members to vote for Obamacare.”
Nothing under serious discussion has so far come close to what some GOP lawmakers are most eager to discuss as the year-end deadline for the tax credits barrels closer: a complete reversal of the ACA. And while appetite within the GOP leadership for gutting the ACA is minimal at this point, vocal opponents of the law could have an influence in a narrowly-divided House Republican majority.
Rep. Rick Allen (R-Ga.) spoke up on a private House Republican call earlier this month in support of redoubling efforts to repeal Obamacare. And Rep. Eric Burlison (R-Mo.), a member of the House Freedom Caucus, said during a teletown hall this week that Democrats’ calls for bipartisan negotiations around the fate of the subsidies are falling flat.
“Well, I’ve got a compromise for them: How about we repeal all of Obamacare?” he said, floating the prospect of a second reconciliation bill.
Conservative opponents of the tax credits say they are too costly and rife with waste, fraud and abuse.
Other Republicans are trying to urge their colleagues away from igniting a politically explosive debate just over a year out from the midterms, recalling the 2018 Democratic wave election that was attributable to backlash from the GOP repeal-and-replace efforts.
Even Sen. Rick Scott (R-Fla.), a longtime critic of the Democratic health law, stopped short when asked if he backed the call from some of his colleagues to nix Obamacare entirely.
“I just think we ought to focus on fixing it,” he said in a brief interview.
Johnson also warned this week that the ACA’s “roots are so deep” that many Republicans are wary of trying to “completely repeal and replace” it. The law now provides coverage for more than 20 million Americans and touches a significant segment of the economy.
“It was really sinister the way, in my view, the way it was created,” he said of the 2010 law. “I believe Obamacare was created to implode upon itself, to collapse upon itself.”
Republicans are now also mired in internal discussions about whether to extend the ACA credits, and what changes they could make to the subsidies to appeal to a broader set of conservatives. They have floated ideas such as instituting new income caps, minimum co-pays, a cutoff for new enrollees and abortion restrictions.
Republicans insist those talks won’t get underway until after the shutdown ends, though some of them also warn negotiations will totally unravel if too many ambitious GOP policy proposals get added to the mix.
Sen. Markwayne Mullin, an Oklahoma Republican who’s been tapped by the White House to work with Democrats on a shutdown offramp, said in an interview this week said the current imperative for government funding negotiations is to “keep it simple” with “some just very easy changes that both sides can agree to and then get in the weeds at a later date.”
“I’m afraid once we dive into health care,” Mullin added. “It’s going to take a while to unpack that.”
