Getting from Obamacare to Trumpcare

Joanne Kenen

About Joanne Kenen

Joanne Kenen, (@JoanneKenen) the health editor at Politico, is AHCJ’s topic leader on health reform and curates related material at She welcomes questions and suggestions on health reform resources and tip sheets at Follow her on Facebook.

Photo: Matt Johnson via Flickr

Photo: Matt Johnson via Flickr

A few quick thoughts on health reform and the election — we’ll be coming back to this, of course, as we learn more (and get more sleep!)

Republicans can’t just repeal the entire Affordable Care Act. Democrats will still have enough votes to filibuster – and they will.

That doesn’t mean President-elect Trump and the GOP majority can’t unravel a great deal of the law. They can – and that’s one reason Families USA and other advocacy groups went into emergency mode to figure out how to defend it.

The ACA statutes gave a lot of authority to the administration, notably the HHS secretary. Republicans complained about this a lot while the HHS Secretary was Kathleen Sebelius or Sylvia Burwell. But once the secretary is – fill in the blank (possibly Ben Carson, but who knows) – he or she will have the ability to change a lot of things through the regulatory/administrative process. That could include loosening mandates, giving states more flexibility in waivers, regulating some things extra aggressively and regulating others not at all, and stopping enrollment and outreach efforts (and the money) for

In addition the Trump administration could – and probably would – stop fighting the lawsuit the House Republicans had filed. That case, now on appeal, sought to stop cost-sharing subsidies, which helped pay the out-of-pocket costs for people under 250 percent of the federal poverty level. (These subsidies were in addition to the financial aid for premiums for people up to 400 percent.) That comes out of the health plans bottom line – but if it happens, the plans are allowed to exit the exchanges, pretty fast.

The list goes on. “Obamacare” would stop looking like “Obamacare” awfully fast.

That’s just the administrative end. Congress could and would still have a crack at dismantling the law, without a filibuster, later in 2017. Legislators could use a complicated budget procedure called reconciliation to undo big chunks of it – enough so that the rest wouldn’t work. Not only could they do it – they did in 2015. The difference is that then it was symbolic – Republicans knew President Obama would veto it. Trump would sign it.

Of course, once the ACA goes away – what replaces it? Good question – and one that neither Trump nor the congressional leaders have answered with any specificity. Lots of legislators and advisers to Trump are calling for some kind of transition period to a new system, to help at least some of the 20 million people getting covered directly through provisions of the law. But we really don’t know what this would look like. Some Republicans want to preserve some of the popular provisions, including letting young adults stay on parents plans until age 26, or requiring plans to cover people with pre-existing conditions. Others do not. It will be some time until we get a clearer picture.

(NOTE: We’re all getting a barrage of expert analysis in our email. I found these two articles particularly useful. Tim Jost is a legal expert and supporter of the law, who spells out some of the scenarios on the Health Affairs Blog. Chris Jacobs is a conservative analyst, who has worked on the Hill and for then- Gov. Bobby Jindal of Louisiana, and he writes in National Review about some of the pitfalls facing Republicans trying to get rid of a six year old law that has taken root in the system.)

For more links to relevant articles on Trump and health care, see “An early look at president-elect Trump’s positions on health care.”

Leave a Reply