It is no secret that replacing the Affordable Care Act, popularly known as Obamacare or the ACA, is high on the agenda of the incoming Republican administration and Congress. Speaker Paul Ryan has said that the law has “failed.” In the campaign debates, Donald Trump said it was “destroying our country.” But even as the new administration has issued its initial executive orders, Republicans have yet to offer a true alternative plan, and the timing on replacement is still hazy.
Given that one party controls both the executive and legislative branches of government, one might be tempted to think that “renegotiate” may be the wrong word — that “fiat” may more appropriate. Not so fast. There are Republican governors who oppose the rollback of Medicaid expansion. Even within Congress there are differences over whether a repeal should take effect immediately or over time. Despite the demonization of the ACA on the campaign trail, there are elements of the law that are quite popular across the political spectrum. While the president has stated on the record that he wants health care for everyone, his nominee for secretary of health and human services refused to back that promise in confirmation hearings.
The policy and politics promise to be nettlesome at best, and many experts are weighing in. At the Program on Health Care Negotiation and Conflict Resolution, at the Harvard T.H. Chan School of Public Health, we look most closely at the leadership and negotiation issues, each of which offers opportunities as well as pitfalls that can be seen clearly even now.
Given the number of stakeholders and the diversity (and divergence) of their interests and points of leverage, “renegotiating” is exactly the right word. And there are few negotiations as complex as reforming the U.S. health care system. Certain changes can be forced into the system from on high, but the essential goodwill, commitment, and voter loyalty that political will is derived from cannot be commanded.
The promise of much better care at greatly reduced costs for citizens is simply a fantasy unless Congress is willing to increase subsidies for coverage. The budget hawks on Capitol Hill are not likely to go along with that. Or they could regulate prices, but that is also anathema to conservatives. Physicians and hospitals will come to the table wanting more now that they better understand the impact of the various components of the ACA. Insurers will remember that Congress funded just 12.6% of their claims under the “risk corridors” of the ACA and will want greater certainty regarding the risks they are undertaking. The public’s expectations are that the parts of the law they like will remain — including the expense-heavy coverage for preexisting conditions and elimination of lifetime benefit caps — while those they dislike, such as the employer and individual mandates that help mitigate risk and lower costs, will go away.