What We Know About ACA Repeal & Replace

December 9, 2016

After six years of campaigning to repeal the Affordable Care Act (ACA) and over 50 votes held to undercut the law, Republicans in Congress will be ‘shooting with real bullets’ in the 115th Congress – thanks in part to the election of Donald Trump – and will finally be positioned to deliver on their long-held position that President Obama’s healthcare law should be repealed as expeditiously as possible. But without a concrete replacement plan in place, Republicans remain at a crossroads over what set of policies should encompass their ACA alternative, and face the politically challenging prospect of deciding how – and how quickly – they will be able to achieve consensus.

The ACA repeal vote will not be easy. There are a handful of crucial sticking points that have divided Republicans – particularly the length of the “sunset” window for repeal of many major ACA provisions. As it stands now, the Republican leadership is eying a plan – with work on a reconciliation bill set to begin on Jan. 3 – that would sustain the ACA for two or three years while they get to work on replacing it. But some in the GOP have expressed concern with the plan to push through repeal without a replacement in waiting. And in the Senate, where Republicans will hold the slimmest of majorities, Majority Leader Mitch McConnell (R-KY) will need to have buy-in from across the caucus to put a repeal bill on Trump’s desk during his first few weeks in office. Meanwhile, stakeholders from across the health care community – hospitals, consumer groups, and insurers, and others – are lining up to oppose repeal without a contemporaneous replacement plan.

When it comes to replacing the ACA, Senate Republicans have already signaled that they will attempt to pass a bill through regular order, requiring 60 votes to pass and the bipartisan support of at least 8 Senate Democrats. “We’re not going to pass another 2000-page bill like the Democrats have,” Senate Majority Whip John Cornyn (R-TX) recently said. “The way to realistically address this is to go step by step, to build consensus, get 60 votes and pass those various pieces.” But even if it has Democratic fingerprints on it, any ACA replacement will largely be shaped by Republicans. Some of the common proposals among GOP-backed plans include fixed-dollar, age-adjusted premium tax credits to take the place of the ACA’s means-tested tax credits; an expansion of health savings accounts; a requirement to maintain continuous coverage to avoid preexisting condition exclusions; federal subsidies for state high-risk pools; and authorization of the sale of insurance across state lines. Whether a handful of Democrats would be willing to sign on to a plan with those major elements remains to be seen. But consider that a starting point.

In our new Issue Brief, “What We Know About ACA Repeal & Replace,” we outline and summarize the most recent developments around the key factors that will underpin the repeal and replace debate in the 115th Congress. Specifically, we examine the timing for a repeal vote, the likely scope for repeal via budget reconciliation, the potential impact of ACA repeal on the insurance markets, and the likely components of a replacement package. If you are interested in accessing the full document, please contact Shea McCarthy (