Since June 2009—before the Affordable Care Act even became law—congressional Republicans have promised to be weeks away from proposing their own blueprint for health-care reform. More than seven years later, House Speaker Paul Ryan still seems confused about whether his party does or does not have a plan ready to replace the ACA. “We already know what we’re replacing with. We’ve been extremely clear with what replace looks like,” Ryan insisted in an interview on Wednesday. The following day found him pleading with a reporter for more time. “We’re just beginning to put this together,” Ryan admitted.
Regardless, Republicans are moving quickly to gut the ACA. Repeal will be the “first order of business” for the new administration, vice president–elect Mike Pence said on Wednesday after speaking to GOP lawmakers on the hill. That same day Senate Republicans began laying the groundwork for a budget maneuver that would allow them to roll back parts of the law with a simple 51-vote majority, thus skirting a Democratic filibuster. Despite the fast pace, the plan is remarkably shaky—not just in detail but also for the lack of political support behind it. Almost no one outside Congress thinks the GOP’s current strategy is a good idea, and even a few Republican lawmakers are getting skittish.
The strategy has been dubbed “repeal and delay.” Republicans could eliminate major pieces of the law within a matter of weeks. But party leaders want to postpone the date the rollback goes into effect, by a couple of years, to prevent disruption in people’s insurance coverage (read, to protect themselves from blowback in the 2018 elections). In the meantime, Republicans promise, they’ll pass a replacement—“something terrific,” to quote Donald Trump.
At risk is federal funding for the Medicaid expansion, which covers people just over the poverty line, as well as the subsidies for insurance purchased in the government-run marketplace. Taxes that pay for expanded coverage would also be eliminated. Ultimately, 22 million Americans could lose their health insurance, according to an analysis by the nonpartisan Congressional Budget Office of a similar repeal effort congressional Republicans passed in 2015. Even if the repeal rolls out on a delayed schedule, uncertainty may provoke insurers to pull out of the marketplaces. Hospitals could bear a staggering financial burden from uninsured patients, leading to “an unprecedented public health crisis,” they warned last month.