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Analysis: 5 Ways Republicans Can Finish Health Care Overhaul

No path is a slam dunk, some options have a better chance than others

House Speaker Paul D. Ryan conducts a news conference with members of the GOP caucus on Capitol Hill on April 6 to announce a new amendment to the health care bill to repeal and replace the 2010 law. (Tom Williams/CQ Roll Call file photo)
House Speaker Paul D. Ryan conducts a news conference with members of the GOP caucus on Capitol Hill on April 6 to announce a new amendment to the health care bill to repeal and replace the 2010 law. (Tom Williams/CQ Roll Call file photo)

Republicans have promised their effort to repeal and replace the 2010 health care law is alive and kicking. And they’re likely to keep going at it until they pass a bill or get elected out office. 

There are at least five different legislative paths for getting a health care overhaul passed before next year’s midterm elections — some more viable than others and none guaranteed to work without support from a majority of Republicans.

The key to all five paths is the budget reconciliation process that would allow the bill to get through the Senate with a simple majority vote. This is the only way Republicans can repeal the 2010 law, as Democrats do not support a repeal measure.

While some moderate Republicans are ready to settle for partial repeal and more incremental bipartisan changes to the law, a majority of the party still prefers a broader repeal and replace measure and is unlikely to abandon that effort anytime soon.

The five legislative paths are:

One more amendment 

The path Republicans are pursuing at the moment is another amendment to the current bill that could get enough conservative and moderate “no” votes moved to “yes.” Talks surrounding such an amendment have been ongoing for weeks, but a final agreement continues to elude lawmakers.

GOP leaders are clamoring for a speedy resolution, with much of the pressure coming from a White House that is looking for a legislative win. President Donald Trump said during a press conference on Thursday that the health care bill continues to get “better and better and better” and that he foresees a vote “next week or shortly thereafter.”

House Speaker Paul D. Ryan said Wednesday at a London think tank event the GOP was putting the “finishing touches” on the measure.

While Republicans believe this is their best shot — their only shot, some think — to repeal and replace the 2010 law, the option appears to be slowly fading. If an agreement over an amendment that will get enough members on board can’t be reached in the next few weeks, it’s likely Republicans will have to begin exploring the other potential paths. 

Repeal first, replace later

The main reason Republicans need to use the budget reconciliation process for health care is to ensure they can repeal the 2010 law without Senate Democrats filibustering. But they could always try to move a repeal measure without any replacement components. 

This move is highly unlikely given strong objections from a wide swath of Republicans. It could, however, be used in desperation. If leadership was willing to bring up a repeal-only bill — currently, they are not — it’s unclear how many members would go on record in voting against something they’ve campaigned on for seven years. 

Conservatives have previously urged leadership to take that gamble and bring up the same repeal bill Republicans passed through reconciliation in 2015. Replacement legislation could move at the same time but through regular order, they argued. 

Also, Democrats may be more inclined to work with Republicans on a replacement measure if a repeal passed successfully. Democrats won’t work with Republicans on health care until they take repeal off the table, House Minority Leader Nancy Pelosi said Thursday on PBS’s “Overhead with Evan Smith.” Passing a repeal would make that point moot.

This far into negotiations, Republicans will look like they’re admitting defeat on a replacement if they move a repeal-only measure. The more likely option is exploring paths that will buy more time to get to replacement.

Switching vehicles

If the health care bus is moving too slow, the GOP could also switch vehicles. Part of the pressure for Republicans to get a health care deal done soon comes from the budget reconciliation instructions from the current fiscal year.

The GOP’s plan in January had been to be done by now with the the health care bill, so they could begin the fiscal 2018 budget process and write new reconciliation instructions for a tax code overhaul — another priority Republicans expect to pursue alone.

One option is for Republicans to reverse their plans and rewrite the fiscal 2017 reconciliation instructions for the tax code changes, and then use the fiscal 2018 vehicle for health care.

The problem is tax overhaul also appears unready for prime time. Republicans have not yet released legislative language to expand on the tax overhaul blueprint they put out last year. That is likely in part because some of the ideas they’ve proposed — most notably the so-called border adjustment tax that would have the United States tax imports instead of exports — do not have enough backing within the party.

While this path is slightly more viable than the repeal-only option, it’s still highly unlikely the GOP will choose to switch the health care and tax vehicles.

Combined efforts 

If both the health care and tax overhauls are not yet ready to move, but could be in a few months time, Republicans could choose to combine the two efforts. The GOP could write fiscal 2018 budget reconciliation instructions for both priorities. 

This option is more viable. It gives Republicans more time to put together both bills and solves the $1 trillion issue that comes with rewriting the tax code before repealing the health care law. Repealing taxes from the 2010 health care law will lower the baseline for tax overhaul by $1 trillion, making it less costly for the GOP to lower tax rates. 

The problem is negotiations are bound to become intertwined with both overhauls moving at the same time. That means Republicans who oppose the health care bill could withhold their support for the tax bill until they get what they want on health care — or vice versa. Such horsetrading could make both bills harder to pass. 

Punting to next year

The final path is for Republicans to abandon their urgency to repeal the 2010 health care law and punt the effort into next year. They will have the fiscal 2019 budget reconciliation process available to them then, keeping their ability to maneuver without Democratic support. 

This move also gives Republicans nearly a full year to work out their differences on the replacement plan.

If that’s not enough time to get it done, the only path forward is the one that leads back home, where the voters decide whether to send Republicans back to the Hill for another term and chance to make good on their promises.

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