EDIT: 19 minutes after this blog posted, the NY Times released this (screenshot taken 1 hr 14 minutes after blog posted).  Keep it in mind as you read.

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For the first time in quite some while, the same political party controls both the Executive branch of U.S. government (the President and the agencies and departments whose heads serve “at the pleasure of the President”) and the entire bicameral Legislative branch (the House and the Senate).  This party is the Republican party, also known as the GOP.  As we approach the inauguration on January 20, 2017, of President-Elect of the United States Donald Trump, the  U.S. Congress is also signaling its intentions.

There are many, but the one that most concerns bioethicists regards the Affordable Care Act of 2010, also known informally as “Obamacare.” This complicated law sought to provide near-universal health care not by using a single payer model, but rather by requiring every American to have health insurance either through their employer, through expansions of Medicaid (the U.S. health insurance program for poor people), or by purchasing private health insurance on the open market. For people doing the latter, the ACA provided income-based subsidies so that folks making too much to qualify for medicare but not enough to pay out of pocket for insurance premiums would receive subsidies from the government that would mean their payments would slide from zero at the low end of the scale (with the federal subsidies paying the entire cost of the premium) to 100% at the high end of the income scale (with the insured person being ineligible for subsidies on the basis of their earned income or assets). Anyone not purchasing health insurance, and not falling into exemptions, would be increasingly penalized by the Internal Revenue Service–America’s tax system–every year that they go without health insurance.

As you may know, while Donald Trump campaigned for the presidency, he commonly promised to get rid of Obamacare, referring to it as a terrible law. However, Trump routinely followed this promise in stump speeches and tweets with another: to replace it with something “awesome” that would reduce the cost of health insurance and still preserve popular provisions of the ACA such as not allowing insurance companies to refuse to cover patients with pre-existing conditions, and allowing adult children to stay on their parents’ health insurance until the age of 26.  This came to be known as “repeal and replace.”

As the new year arrived, Congressional Republicans began taking measures to repeal the ACA as soon as they returned to work.  This “repeal strategy” would proceed without a ready replacement to hand. Indeed, estimates were that it would take 2-3 years to devise and pass a replacement.  In the meantime, according to one nonpartisan study, simply repealing the ACA would cause at least 30 million people to lose their access to health care by causing them to lose their health insurance. This would occur because people who could now afford to buy their own insurance with the help of a subsidy would no longer be able to do so, and because the Medicaid expansion would be rolled back so that many more people would no longer have access to this program because they would be considered to be making too much money to qualify even as they clearly make too little to afford to buy health insurance. Last week, President Barack Obama published yet another piece in a medical journal regarding the ACA. The New England Journal of Medicine gave him their Perspectives venue for a piece entitled “Repealing the ACA Without a Replacement–The Risks to American Healthcare.” In it, Obama lays out in plain language some of the tradeoffs he accepted in the design of the ACA and points out that any replacement will have to face a similar calculus: how do we require insurance companies to cover people with pre-existing conditions without burdening them to the point of non-existence?  Obama closes by saying “I will applaud legislation that improves Americans’ care, but Republicans should identify improvements and explain their plan from the start — they owe the American people nothing less.”

Precisely because of such considerations, within days of GOP promises to repeal the ACA as soon as possible, dissent even from Congressional Republicans began. Senator Rand Paul, who was an early candidate for the Republican presidential primary, wrote an editorial critiquing any “repeal strategy” that doesn’t involve simultaneous “repeal and replace.” On Sunday, January 8, however, majority leader Mitch McConnell (Republican) said on CBS’s “Face the Nation” that Republicans “will be replacing it rapidly after repealing it.”  This again separates in time–an uncertain amount of time–repeal of the ACA from any replacement, which has yet to be proposed.

MITCH MCCONNELL: Well, I haven’t heard Senator Paul’s plan to replace it. But we– we will be replacing it rapidly after repealing it.

JOHN DICKERSON: So can you give me a sense of what rapidly means? Are we talking–

MITCH MCCONNELL: Very quickly.

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JOHN DICKERSON: Months? Days?

MITCH MCCONNELL: Quickly.

JOHN DICKERSON: All right. But it’s going to be repealed by the end of this week, you think?

MITCH MCCONNELL: The first step will be taken in the Senate by the end of this week, yes. And then it’ll go over to the House.

Interestingly from the perspective of bioethicists concerned about access to health care, McConnell went on to say this:

JOHN DICKERSON: On replacing it, if I have—if I’m covered now as part of Obamacare, am I going to be covered by the replacement?

MITCH MCCONNELL: Well, what you need to understand is that there are 25 million Americans who aren’t covered now. If the idea behind Obamacare was to get everyone covered, that’s one of the many failures. In addition to premiums going up, co-payments going up, deductibles going up. And many Americans who actually did get insurance when they did not have it before, have really bad insurance that they have to pay for and the deductibles are so high that it’s really not worth much to them. So it is chaotic. The status quo is simply unacceptable. And at the risk of being repetitious, if Hillary Clinton had been elected, we’d be revisiting Obamacare.

Can the GOP come up with a replacement for the ACA that will be better than the ACA and will be able to get passed through the legislature and not vetoed by then-President Trump?  What would that look like?

Given that the ACA is based on a model implemented in Massachusetts by Republican Governor Mitt Romney, and had its origin in the conservative Heritage Foundation thinktank, this editor wonders what a conservative Republican alternative to the ACA might look like, and whether it would truly be superior to the ACA. I also wonder how a GOP plan will counter rising costs that have been rising since long before the ACA, and which slowed down and even dropped for a bit after the ACA passed but are now rising again consistently with long-term trends.

These costs are what McConnell is saying the ACA did not address.  Can any replacement address them better?  If so, would it require a level of government intervention in pricing that conservatives have traditionally rejected on ideological grounds to which they are deeply and, often principally, committed.

Repealing without replacing may now be dead in the water. We will still have to keep an eye on this “repeal” or “repeal and replace”, and with what.  Maybe even a bit of side-eye now and then.