The Republicans' dream to repeal Obamacare died earlier today. What happens now? There are several possibilities.

Senate Majority Leader Mitch McConnell worked feverishly for the last several weeks to get a bill through the Senate that would repeal and replace Obamacare, in tandem with the American Health Care Act that passed in the House back in May.

Getting that bill through the House took a lot of effort, even though Republicans hold a sizable majority there. In the Senate, however, they hold only 52 of 100 seats, plus Vice President Mike Pence, who can vote to break a tie. At the moment, their majority is even thinner than usual, because Arizona Republican Senator John McCain is temporarily sidelined due to cranial surgery.

From the beginning, Senate Republican leaders knew there would be serious obstacles to passage of an Obamacare repeal. Yesterday evening, McConnell was forced to admit defeat for the Senate version of Trumpcare, called the Better Care Reconciliation Act, after four Republican senators announced they would not support it. (Even if they had waited until McCain was able to vote, Senate Republicans could afford to lose only two votes from their own party.)

At the urging of President Donald Trump, McConnell then suggested a vote to simply repeal Obamacare (officially the Affordable Care Act) with no replacement, but with a two-year delay. The idea was to allow for an orderly transition to some other law that Republicans could presumably pass by then. That effort, too, died a fiery death when three moderate Republican senators announced they would not support a simple repeal bill. McConnell says he will still go ahead with a vote early next week. It is always possible that two of the recalcitrant senators will change their minds before then.

But if not, insurers, politicians, health care providers, and millions of Americans are left to wonder what happens next. Here are some possibilities for the future for American health care. Some of them are rosier than others:

1. President Trump leaves Obamacare in place but destroys it by not funding it.

Sadly, this seems to be the most likely of the possible outcomes because it's what Trump has basically said he'd do. "I've been saying for the last year and a half that the best thing we can do is let Obamacare explode. It's exploding right now," he told reporters after repeal failed in the Senate. It is certainly true that insurance premiums went up sharply this year, that they look like they'll go up sharply again next year, and that some insurers are pulling out of some markets for individual insurance, meaning that more than 50,000 Americans may have no health insurance available to buy at all in 2018.

But if Obamacare really is exploding, it's largely because of Republicans' efforts to repeal it. Insurers were understandably hesitant to sell insurance in the Obamacare marketplaces (or "exchanges") when they thought those marketplaces would close in a year or two.

Even if Republicans now abandon their efforts to repeal the ACA, insurers are left with a dilemma over how to set their premiums. The "Affordable" part of the Affordable Care Act was a set of subsidies that allowed most participants in the exchanges to buy insurance at substantially less than its true cost, with the Federal government subsidizing the rest.

The Republican-led House sued the Obama administration over those subsidies, arguing that the money for them had not been appropriated properly. The Obama administration fought that suit in court. So far, the Trump administration has chosen to neither continue to fight the lawsuit nor officially end the subsidies.

As things stand, insurance companies are forced to make plans for open enrollment without knowing whether those subsidies will be paid in 2018 or not. Faced with so much uncertainty, it's hard to blame them for pulling out of some markets and enacting sharp premium increases in those where they stay. As just one example, Blue Cross/Blue Shield of North Carolina says it will raise premiums about 23 percent next year, but would only have raised them about 9 percent if it knew that the subsidies would continue.

"I'm not going to own it."

If and when Obamacare explodes, Trump promises to disavow any responsibility for the carnage. "I think we're probably in that position where we'll let Obamacare fail," he told the press today. "We're not going to own it. I'm not going to own it. I can tell you the Republicans are not going to own it."

Maybe, maybe not. Voters may be disinclined to blame a popular former president who's been out of office for six months or more when they suddenly can no longer afford insurance, or find any to buy. They may be likelier to blame the guy sitting in the top spot right now. Some analysts believe this dynamic will force Trump to fund Obamacare rather than let disaster happen on his watch.

2. The Senate tries again with another bill.

Right now, that prospect looks highly unlikely, with both Trump and McConnell saying that they're giving up on an Obamacare repeal and turning to other matters, such as tax reform. Neither has given the slightest indication that a new version of the bill will be introduced in the Senate anytime soon, or ever.

On the other hand, politicians change their minds all the time. Trump's promise not to own it notwithstanding, the collapse of an Obamacare repeal--which just about every Republican in office campaigned on--is a huge embarrassment for the party. Rather than live with that embarrassment, they may very well be tempted to take another shot. Trump is justly famous for his ability to cajole or compel others to do what he wants, so he may well succeed in bringing resistant senators back into line next time around.

3. Republicans and Democrats actually work together.

Do you remember the last time that happened? Me neither. So this is admittedly a long shot. But prominent Republicans, including McCain (who's been issuing statements from his sickbed) and Ohio Governor John Kasich, have called for the two parties to do just that. And Democratic Senator Joe Manchin of West Virginia organized a meeting of senators from both parties who are also former governors to discuss ways of stabilizing and preserving the existing markets under Obamacare.

At this point, neither party has much to gain by refusing to work with the opposition. As McConnell noted, unless there's a surprise change of heart, the planned vote will demonstrate "that Republicans by themselves are not prepared at this particular point to do a replacement and that doesn't mean the problems all go away." Meantime, Democrats, who control neither the Senate, nor the House, nor the presidency, are in no position to make sure Obamacare gets the funding it needs to work well.

When all else fails, try negotiating with the enemy. That might even apply to politicians.

Published on: Jul 18, 2017
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