What the Republican win might mean for the Affordable Care Act

Image by  ofacalifornia via flickr.

Image by ofacalifornia via flickr.

Come January, the Republicans will have big majorities in the House and the Senate – majorities they have not had since President Obama took office or since the Affordable Care Act was passed along party lines in 2010.

Now what?  Even the Republicans are figuring that out  – but here’s some of what we know.

The Senate and the House will both have ACA repeal votes. Such a vote will win overwhelmingly in the House and, in the Senate, the Republican majority is also expected to vote against the ACA (or for a procedural motion related to a straight out repeal vote) but it will still fall short of the 60 needed to clear a filibuster.

Then both chambers are likely to target specific elements of the health law. The Senate can either do that through a budget process known as reconciliation (which is complicated – but it requires only 51 votes) or by specific targeted measures. The key targets include:

  • Repealing the medical device tax – there’s some bipartisan support for this and it could go, as Jason Millman explains here.
  • The elimination of the Independent Payment Advisory Board on Medicare spending. Members have never been appointed, and with Medicare cost growth historically low the past few years, the trigger to set off IPAB cuts won’t be used anyway. It’s  hard to see Democrats falling on a sword to save  this one.
  • The 30-hour-work-week employer mandate. This one is trickier. The ACA says that employers covered by the employer mandate must cover full-time workers, and it defines full time for this purpose as 30 hours. Republicans want to change that to 40. (There are a lot more workers in danger of having a 40-hour week cut to 39 than there are 30-hour workers cut to 29.) Here’s an argument in favor of the 40 hour change from the National Retail Federation (a big force behind the move to change it).  Here’s the Center for Budget and Policy Priorities explaining the other side.

Instead of the change in the work week, the GOP could instead try to repeal the whole employer mandate, which has been delayed twice and is being only partly phased in during 2015. Even a lot of liberals have come to think the mandate was poorly designed and/or causing more political problems than it’s worth.

Are these the only changes the GOP will seek? It’s too early to know. Republicans could use the appropriations process to cut or reduce spending on the law, or they could tie up legislation that President Obama wants (related or unrelated to the ACA) by including ACA-language as well.

We don’t know yet whether the course for the next two years is going to be purely confrontation and repeal or whether some deals could be cut. Certainly the president won’t sign a repeal of the law, or the individual mandate, or any other true core provisions. But can he accept certain changes if it lowers the heat and allows everyone to move on? Time will tell – although the prospect of another Supreme Court case, threatening the subsidies through HealthCare.gov, may mean any serious talk of compromise is delayed until that ruling, which is expected in June.

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