WASHINGTON — President Trump and House Republicans are pressing forward with a high-risk strategy to repeal and replace the Affordable Care Act, disregarding the views of medical professionals and potentially imperiling the party’s political future in conservative states where many voters stand to lose their health care.
The effort could cause upheaval in a roiled insurance market next year, as Republicans face voters for the first time with Trump in the White House — though that turmoil would happen only if the plans manage to clear a divided Senate.
Trump is showing only a tenuous grasp of the legislative process and mercurial leadership in rounding up support. But Republicans who spent seven years promising to scrap President Obama’s signature domestic achievement say their strategy is worth the risk.
“If you ask someone to give up something, there will be resentment,’’ said Representative Michael C. Burgess a Texas Republican who chairs the Energy and Commerce subcommittee on health. But, he added, “If that claims my congressional career, so be it. It will be worth it to me to have effected this change.’’
The risks mounted steadily last week. The insurance and health care industry cited likely damage to medical coverage for millions of Americans. Conservatives fought the bill on the grounds that it did too little to reduce subsidies. And House leaders moved forward even though the influential Congressional Budget Office has yet to assess the costs or effectiveness of the plan.
Ultimately, Republicans are counting on Democrats to step in and help repair what even Republicans anticipate as upheaval if a repeal measure is passed without a broad remake of US health care.
Republican leaders have made no effort to hide the strategy. House Speaker Paul Ryan spoke at length last week about a three-stage effort: First, repeal the health law with only Republican votes. Second, let Health and Human Services Secretary Tom Price use regulatory powers to try to stabilize roiled insurance markets. Third, pressure Democrats to help with a series of bills to complete the replacement measure and change the health care system more to the liking of conservatives.
But that bet carries enormous peril for consumers and insurers — and congressional Republicans and the Trump administration.
Democrats, eyeing potential turmoil in the run-up to the 2018 midterm elections, have little political reason to cooperate before those campaigns. “One thing is clear,’’ said the House Democratic whip, Representative Steny Hoyer of Maryland. “House Republicans are going to have to find the votes on their own to dismantle the protections incorporated in the Affordable Care Act that the American people now have.’’
A growing chorus of Republican policy experts and senators are pleading to slow the process down — or risk a political blood bath. But Republican leaders and Trump appear to be laying the groundwork for blaming the law they are annulling for the fallout likely to come in the repeal’s wake.
What is clear is that 2018 — a year that Republicans say will be messy — will loom large for them as they move toward a vote on the measure. But Republicans say that gives them nearly a year of time, since people will experience few changes with their health care in 2017.
Under the proposed House legislation, individuals would no longer be subject to a penalty if they go without health insurance, a politically popular change that would be retroactive to 2016. But they would still enjoy the protections of the Affordable Care Act: Insurers would have to offer a suite of essential health benefits, could not deny them coverage because of pre-existing conditions, and could not impose annual or lifetime caps on coverage.
Insurers would be free to raise their premiums to meet these requirements, but because current policies are locked in for the year, voters would not see the effects until 2018. If young, healthy Americans flee the market, freed from the mandate, premiums could soar next year.
Insurers say this is a recipe for havoc. Eliminating the penalties to enforce the mandate that most Americans have insurance “would add to short-term instability in the market,’’ said Marilyn B. Tavenner, chief executive of America’s Health Insurance Plans, a lobby for insurers.
Instead of the current tax penalty for failing to secure coverage, the bill would introduce a penalty for purchasing insurance after letting coverage lapse: To encourage people to maintain “continuous coverage,’’ insurers would impose a 30 percent surcharge on premiums for people without coverage for 63 days or more.
But that provision would not take effect until 2019 — again leaving 2018 unprotected.
Deep Banerjee, who follows insurers for Standard & Poor’s, estimated that the Republican plan would reduce enrollment in the individual market by 2 million to 4 million people and in the Medicaid market by 4 million to 6 million. Brookings Institution analysts predicted that the budget office would expect the bill to cause the number of uninsured to rise by at least 15 million.
