"We want to repair the ACA and I have never favored its repeal without a replacement," said Rep. Leonard Lance
of New Jersey. "I think it needs to be repaired and we are trying to focus on repairing it and that is why we're conducting this hearing along with other hearings."
For some supporters of the program, such statements will bring a little relief. Could this be the beginning of the long-awaited backlash to Trump's rightward agenda that liberals have been waiting for? Are Republicans in Congress rethinking their opposition to the ACA in light of concerns that constituents will lose access to health care, or because of the push-back from an insurance industry troubled by uncertainty?
While the challenges of dismantling the ACA are serious, so, too, is the determination of a united Republican government aware of the damage it can inflict on a key part of Obama's legacy. The change in terminology -- from repeal to repair -- may well just be a strategic semantic move, something Republicans have been brilliant at when dealing with former President Obama's health care program.
Throughout the debates over health care -- from when Obama proposed the program to the moment Congress finally passed the legislation, to the years that followed -- the GOP has used the language through which they talked about the policy as a political tool.
Early on, Republicans brought up topics such as death panels, and dubbed the plan "Obamacare" to try to delegitimize the program. When there was a backlash to the notion of repealing the program, they introduced the concept of "repeal and replace" to soften the opposition. Now, as they grapple with the mechanics of actually eliminating the program, it seems Republicans are going back to the rhetorical playbook to see what words might be employed to establish better political conditions for moving forward.
In fact, it is not at all clear that this is a major retreat. The very first executive order
to come from the White House centered on instructions to all the agencies to do what was necessary to undercut the ACA. Given that most of the agencies are going to be led and staffed by conservative critics of the program, this announcement in itself creates a massive threat to the program. With fierce ACA opponent Tom Price in charge of the program, Obama's supporters should be cautious about celebrating any possible change of heart.
Even if the ACA remains on the books, if agencies don't enforce key components of the policy, such as the individual mandate, and if they don't devote the resources necessary to properly administer the program, this federal policy will be vulnerable.
We have already seen some of the effects. In the final days of the enrollment period, which is critical to ensure a sufficient number of healthy individuals are in the program so overall insurance costs go down, the administration pulled advertising and outreach efforts that were intended to make Americans aware of the deadline. The New York Times reported that there was a 4% decline
in the total number of Americans signed up through healthcare.gov as a result of these efforts. "Trump's sabotage worked," lamented the spokesman for former Secretary of HHS Sylvia Mathews Burwell.
Even as far as the ACA and Medicaid are concerned, and this was one part of the ACA that has always been popular with the public, there is a serious, longer-term threat. Even if Republicans suggest that they might allow the ACA Medicaid enrollments to continue, the fact is that congressional Republicans are pushing for a major transformation of this program, put into place in 1965 as part of the Great Society.
Republicans are eager to transform Medicaid into a block grant, an idea some in the party have been pushing since Ronald Reagan entered office in 1981. The result would be that rather than providing an open-ended right to health care, states would obtain a chunk of money and would have much greater discretion to make cuts and redesign policies in the manner they wanted. But a shift to a block grant would result in huge reductions in federal spending, which would then likely require states to cut eligibility and benefits. If this happened, Medicaid enrollees might find their benefits at risk.
This might be academic, though, because there is broad -- and understandable -- skepticism over whether Republicans are really rethinking repeal in the first place.
Since the 1990s, when pollster Frank Lunz instructed Newt Gingrich and his colleagues on how to use and manipulate language to soften the blow of tough policies that conservatives pursue, there have always been semantic games coming out of the GOP aimed at masking the actual effects of their policies. For example, when President George W. Bush pushed for an incredibly regressive tax cut in 2001 that primarily benefited wealthier Americans and business, the administration went to great lengths, as the political scientists Paul Pierson and Jacob Hacker have shown, to put out promotional rhetoric that suggested this was a tax cut for average middle class Americans.
Given how central eliminating the ACA has been to the Republican agenda -- and what it would mean symbolically for President Donald Trump to back away from this promise at a moment of united government -- there is reason to be skeptical that this change in rhetoric will lead to a substantive shift in policy.
Indeed, members of the Freedom Caucus are already making their views clear.
"I'm hearing a lot of members say that they want Obamacare-lite," warned
the tea party Republican Rep. Raul Labrador of Idaho, "That's not what we promised the American people." As we have seen during the Obama presidency, if the Freedom Caucus is united on an issue and determined to hold its ground, there is little that the Republican leadership can or will do to overcome it.
So yes, the ACA might survive the moment. And we have seen how some programs, like Social Security or the Earned Income Tax Credit, gain so much support after being on the books for a number of years that retrenchment becomes nearly impossible given how many beneficiaries emerge.
Yet it is far too early for ACA supporters to be so optimistic. The risks to the program are very real in the coming months. Rather than listening to what Republicans are saying, Democrats would be better served to watch what they are actually doing.