How Obamacare Could Change Under a Republican Senate

The Senate majority leader, in waiting.

Photo by Win McNamee/Getty Images

Having retaken the Senate, Republicans are finally in a good position to nip away at bits of the Affordable Care Act. Conservatives still don’t stand a chance of repealing it in full so long as President Obama wields veto power. They probably won’t be able to rough up its core provisions like the Medicaid expansion. But health reform was a sprawling law with a multitude of moving parts—many obscure, some widely disliked—and as Texas’ Ted Cruz has said, the GOP is ready to attack the legislation “piece by piece.” Presumptive majority leader Mitch McConnell says he will use the budget reconciliation process to pass changes, which would prevent Democratic filibusters. Within the next couple years, it seems likely that conservatives will have made a few dents in Obamacare.

To see why, you just need to look down the length of the Republican wish list (Jonathan Cohn at the New Republic and Jeffrey Young at Huffington Post have provided good summaries). Top on the list would be repealing the individual mandate, which is unpopular with the public. But eliminating it could make insurance on Obamacare’s exchanges far more expensive, since many young and healthy Americans, whose premiums keep coverage cheaper for everybody else, might choose to go without health plans. That’s why the mandate is a linchpin of the law, why Republicans tried to cut it down at the Supreme Court, and why Obama would likely veto any effort to get rid of it now.

The GOP would also love to do away with Obamacare’s “risk corridors,” which they’ve very misleadingly dubbed “the insurer bailout.” The provision, which expires in 2016, creates a pool of cash that pays out to insurers in the event that they accidentally sign up too many unhealthy patients on the exchanges. It’s funded by fees on the industry, and it’s necessary because health plans are still figuring out exactly how high to set their premiums in a post-Obamacare world—some might undershoot. Since getting rid of it or any similar protections could drive companies away from the exchanges, it seems likely that Obama would exercise his veto vigorously to protect them.

But there’s much lower hanging fruit out there. The GOP will likely seek to do away with the medical device tax; 79 senators, including liberals such as Elizabeth Warren, already voted to repeal the levy last year. While the Independent Payment Advisory Board—better known as the “death panel”—has been in the GOP’s crosshairs since Obamacare was being debated in the Senate, the president has failed to appoint anyone to the committee, which theoretically was intended to rein in Medicare spending by cutting fees to providers. Meanwhile, the administration has already delayed the employer mandate, which requires businesses with 50 or more workers to offer full-time employees insurance or face a fine. Ezra Klein has argued that the employer mandate is so poorly designed that it should be repealed; Cohn says scrapping or tweaking it might be “the most defensible Republican idea” for reform.

Alternatively, the GOP might pick up a Democratic idea. The insurance industry would love to be able to sell lower-cost, higher-deductible “copper plans” on the exchanges that don’t meet Obamacare’s current quality standards. Alaska’s Mark Begich, who was defeated last night, introduced a bill that would have allowed it, and one can imagine the GOP picking up his torch.

The above probably isn’t a full list of potential dings to Obamacare, but you get the picture. Especially if the GOP forces a budget showdown with the potential for a government shutdown, it’s easy to imagine Obama giving ground on at least one of these issues, especially the ones that aren’t absolutely crucial to the functioning of the law—expect to see some changes to Obamacare around the edges.