What happens to Obamacare if GOP wins the White House?

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Getting elected president might be a lot easier for a Republican than getting rid of Obamacare afterward.

For more than half a decade, the GOP has blasted President Barack Obama's signature health-care reform legislation, and the law remains deeply unpopular with the party's base.

But experts say a Republican president would have to clear a very high bar in getting Congress to kill the Affordable Care Act outright, even though GOP candidates have called for doing that.

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Reforming and improving the ACA is a much more likely option, they say, noting that even Democratic contenders like Hillary Clinton and Sen. Bernie Sanders have called for making changes to Obamacare, such as eliminating the "Cadillac tax" on pricey health plans.

"I don't think there's much chance, at all, of repeal at this point," said Drew Altman, president of the Kaiser Family Foundation.

However, Altman said that if a Republican wins the White House next year, and if the GOP retains control over both houses of Congress, "you can expect another big debate about the ACA in 2017, which will focus on substantial changes to the law."

We have a climate right now where even a rational, conservative approach can't get votes. You'd have to have a different kind of leadership, you'd have to have the kind of leadership that would stand up to the right wing of the Republican party.
Robert Laszewski
Health Policy and Strategy Associates

But he added that "it's very hard to say what those changes will be." Altman noted that the proposals GOP contenders are making now are not necessarily those that would turn up in actual legislation. He and others also said that it's difficult to predict whether any substantial changes to Obamacare would actually get passed into law.

Congress' own rules as well as the GOP's poor track record of late in getting its own members to agree on legislation, present hurdles to repealing as well as reforming the ACA.

The Senate's parliamentarian has told GOP Senate staffers she is skeptical that Obamacare can be repealed outright without at least 60 votes in that chamber, according to an analyst at a conservative think tank who has spoken to staffers. That's because 60 votes are necessary to overcome a filibuster, and because the parliamentarian has indicated she believes repeal would have to come from a bill, which can be filibustered. Some Obamacare opponents have called for the law to repealed through so-called reconciliation, a special budgetary procedure that requires only a simple majority of senators to pass.

The GOP currently holds 54 Senate seats. Few, if any, analysts are predicting the Republicans will pick up six more seats in 2016, since the GOP will be defending 24 seats, 14 more than Democrats.

"In my mind, it's impossible to get a 60-vote coalition" to kill Obamacare, said health insurance expert Robert Laszewski, who operates Health Policy and Strategy Associates in Virginia.

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Laszewski noted that at least one key component of the ACA is popular with the public: the provision that bars insurers from denying coverage to people with pre-existing medical conditions, or charging them more than others. Repealing that provision, he said, is very unlikely, despite some Republicans proposing plans that would do just that.

And he said that any move to repeal the ACA's expansion of Medicaid benefits, which 30 states have adopted, likewise would spark a political backlash because it would end coverage for millions of newly insured people under that program, and deny hospitals and other health providers in those states the windfall of federal dollars that pays for those people's care.

Laszewski, like Altman, believes that reform of Obamacare is the likelier option under any new Republican president. But winning the White House and maintaining majorities in Congress won't necessarily mean that substantive changes to the law could get passed, he said.

House Republicans, despite controlling that body, are currently unable to elect a new speaker. And the most right-wing members of the House have been unafraid to buck the wishes of leadership on legislation if they believe the bills aren't sufficiently conservative.

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That dynamic, if it continues in the next Congress, might mean that efforts to reform the ACA could face their toughest opposition from the right, not from Democrats whose own fellow party member, Obama, got the law passed.

"We have a climate right now where even a rational, conservative approach can't get votes," Laszewski said. "You'd have to have a different kind of leadership, you'd have to have the kind of leadership that would stand up to the right wing of the Republican Party ... some leadership to say, 'We've got to cut this out, and we need to govern.'"

Laszewksi believes there is a third option beyond repeal and replace by Congress, an option that is much easier for a Republican president to pursue once elected.

He said that much of Obamacare can be changed through regulations, as opposed to legislation.

For instance, a Republican administration could grant waivers to states that would give them much more control over Medicaid, allowing them to do things such as requiring people to have a job if they receive benefits, and requiring enrollees to pay at least some premium for their coverage, Laszewski said.

And a Republican president could address concerns that individual insurance plans under Obamacare remain too expensive by loosening regulations on insurance companies, allowing the monthly premium prices on lower-value plans to come down to a level that would make them more affordable to many people who remain uninsured, he said.