President-elect Trump created a huge challenge for himself by vowing to repeal Obamacare and replace it with “something great,” with details to follow the election. Now he must deliver without creating a lasting political liability for his new administration.
Repeal is easy. The money aspects of Obamacare—subsidies to make insurance affordable, penalties for not having insurance, expanded Medicaid funding and added taxes—can all be scrapped by using the budget reconciliation process that requires only a majority vote in each chamber and the president’s signature.
But repeal by itself would create a human and political disaster. At least 20 million people would lose their health insurance; millions of others would be unable to buy affordable coverage in a chaotic individual insurance market; many doctors, hospitals and other health providers would lose paying customers; and states would feel the pinch of cuts in federal Medicaid money. Ironically, many of the states that made the most dramatic progress reducing their uninsured populations under Obamacare, and would suffer the most disruption from repeal, are the Rust Belt and Appalachian States that put Trump over the top. To avoid starting the new administration in a political hole, “Repeal” must be followed promptly by “Replace” (with a smooth transition between the two), as the president-elect himself pointed out on “60 Minutes.”
The political challenge is that the replacement for Obamacare must have broad bipartisan support—and not just because Republicans have only 52 seats in the Senate and need 60 votes to quash a filibuster. More importantly, as the history of Obamacare illustrates, health reform supported by only one party is unlikely to survive in this deeply polarized nation. If President Trump is to create a lasting legacy in health care, not just another political football, he needs buy-in from most of his own party and a significant fraction of Democrats.