Here's what the GOP will rip out of Obamacare to get a deal

After Republicans pow-wowed on Obamacare on Wednesday, Vice President-elect Mike Pence came out vowing to repeal the law. Meanwhile Senate minority leader Chuck Schumer, after huddling with President Obama and other Democrats, insisted the GOP has no replacement and that repeal will lead to "chaos."

But while this is starting out looking like another nasty D.C. gridlock fight, don't be surprised if we actually get a deal.

Sure, this is starting out looking pretty ugly. The outgoing president is trying to figure out how to save the Affordable Care Act or salvage as much of it as possible, as the incoming president is warning Republicans in tweets to be careful not to drag their feet and allow the status quo to continue.

And the status quo is a mess. Despite all kinds of promises from both sides, Democrats and Republicans in Washington have never really gone to the bargaining table on Obamacare. That's a disgrace because this is a law that affects all of us in the most intimate of ways. Instead of coming to a compromise deal that most of American voters would accept, President Obama and the Democrats used their super majority in Congress from 2009-2011 to enact the existing ACA. And when the Republicans took control of the House in 2011 and the whole of Congress in 2015, all we saw from their side was repeal vote after repeal vote.

But now that a much less ideological President-elect Trump is coming to the White House, there's a chance of some real deal making in the near future. It sure seems like Trump wants to pass something real to replace Obamacare or else his party will own all the bad news and bad health care cost realities to come.

And it's going to take negotiation with Democrats to make it happen. The question is: What kind of health care bill or policies will Congressional Republicans and Democrats agree on that President Trump will still support? The best way to arrive at the answer is to look at a few of the existing provisions in the ACA that have the best chance of surviving and those with the shortest expected lifespan.

The first deal that seems most likely to happen, IF everyone is willing to sit down and negotiate, is nixing the coming so-called "Cadillac Tax." That tax is a 40 percent levy on what employers and workers jointly pay for an employee's health coverage above a certain threshold — $10,200 for individual coverage and $27,500 for family coverage. The problem is, the plan is supremely unpopular for unions because high-end health-care benefits are among the most valued parts of negotiated labor contracts.

Given the Democrats' need for support from union leadership, Trump's impressive rank-and-file union voter support, and Republican opposition to the tax because most CEOs hate it too, and you could say the Cadillac Tax has about the same life expectancy as one of those red-shirted extras on "Star Trek."

Second, Trump has long been a supporter of the traditional Republican argument that the cost of health coverage will at least be forced down a bit by allowing insurance companies to compete across state lines. The funny thing is that most big insurers have thrown cold water on this notion for a long time. But given the extra work they would have to do to compete in a truly national market, it's hard to take their word for it.

"Despite all kinds of promises from both sides, Democrats and Republicans in Washington have never really gone to the bargaining table on Obamacare. That's a disgrace."

Whether Trump will also favor the longtime GOP call for more tort/malpractice reform to lower the cost of health care is not as clear. But his decision to nominate physician Tom Price as Secretary of HHS should give us a pretty good hint that a Trump-favored call to cap medical malpractice awards is in the works too.

Democrats, Obama pep talks or not, would be unwise to block these provisions. They are relatively minor and generally popular.

But now we come to the harder issues. The GOP is going to want to rescind the individual mandate to have health insurance and the tax penalties that come with flouting that mandate. It's also going to want to provide tax credits instead of subsidies for Americans who can't afford existing premiums.

And then we have the hardest question of all: How can the government continue to force insurance companies to provide coverage to the sick, the elderly, and people with pre-existing conditions that could not get coverage before Obamacare?

Based on his own statements, and because he's not politically suicidal, Trump will want to keep that coverage for Americans with pre-existing conditions no matter what. Democrats will pretend that he won't be able to do that without the individual mandate and the tax penalties, but that argument is weakened by the fact that the mandate and the penalties aren't covering the costs right now. Money is going to have to come from somewhere to make up for this gap.

Again, judging from the nomination of Tom Price, we can assume Trump and the GOP's plan will be to divorce health coverage from its existing place as part of most of our salaries and make it a more portable, self-purchased affair.

Price and most of his Republican colleagues have always promoted the idea of giving people tax credits to buy health insurance on their own while hoping that employers that are no longer required to provide health insurance will use that saved money to pay workers more.

And for the people with pre-existing conditions who still cannot afford their more expensive premiums, this will no longer be their employers' problem. Price, Trump and the rest of the GOP will likely propose that a special federally controlled or state-run,(with federal help), risk pool would probably be established to get them covered. This is in essence a "Back to the Future" approach because opponents of the Obamacare plan in 2009 and 2010 proposed the above risk pool plan instead. But of course, since no one was making any deals back then, it was a non-starter.

So why will it be different this time? On the Republican side, the Trump pressure factor should get the ball rolling for something other than just a repeal and grandstanding.

On the Democratic side, it's going to be a lot tougher. We learned that right after President Obama's meeting with the Congressional Democrats Wednesday. The leading Congressional Democrats including Senate Minority Leader Chuck Schumer, House Minority Leader Nancy Pelosi, and Senator Bernie Sanders came out of that meeting, looking like they're going to dig in their heels and oppose any changes to Obamacare. They even trotted out a nifty "Make America Sick Again" poster just to fire a personal shot at Trump himself.

With majorities in both houses of Congress, it's possible the Trump/GOP plans to change Obamacare could pass without a single Democrat voting for them. That would just be a repeat of the same nasty situation that put Democrats out of power in Washington and so many state capitols across the country.

At some point, Democrats who want to stay in office will realize that soon-to-be-former President Obama won't be able to bail them out any better in Congressional elections than he was when he was in the White House. And several Republicans in contentious 2018 House races will be willing to vote for some of these reforms. And considering the fact that there are 25 non-Republican U.S. Senators up for re-election in two years, don't be surprised if one or two of them finally agree to some kind of a deal.

Based on the new sheriff in the White House and those unique 2018 election year mathematics, real health care policy deal making seems likely. It just might have to wait until a little more time has passed so everyone can move on from eight years of knee jerk obstinacy.

Commentary by Jake Novak, senior columnist. Follow him on Twitter @jakejakeny.

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