Donald Trump’s Allies Can’t Stop Talking About Restarting The Obamacare Wars

It sure sounds like another prominent Republican is looking to roll back key parts of the Affordable Care Act.

Sen. Tom Cotton (R-Ark.) told NBC News on Tuesday night that Republicans could take up significant health care policy reforms if they emerge from the November election with governing majorities. Cotton was speaking to reporters in the “spin room” following Tuesday night’s vice presidential debate in New York City.

“We’ll have an opportunity next year, when it comes time to extend the Trump tax cuts, to adopt new policies that again will make health care more affordable and more personalized,” said Cotton, who was speaking on behalf of former President Donald Trump’s campaign.

His reference to the Trump tax cuts was about a series of breaks Republicans enacted in 2017 that are set to expire at the end of this year.

Cotton went on to specify that Republicans could enact health care reforms by using the budget “reconciliation” process, the protected legislative track for fiscal issues that allows bills to get through the Senate with a simple majority rather than the 60 votes it takes to overcome a filibuster.

The statement is notable because even the most optimistic election scenarios for Republicans envision their post-2024 majority falling well short of 60 members.

Health care was a topic of discussion in the debate spin room because it had come up in the debate, following a seriesofstatements by Trump and his running mate, Sen. JD Vance (R-Ohio), that they were still interested in repealing and replacing the Affordable Care Act, aka Obamacare.

Trump (as usual) has not specified what kind of replacement he has in mind, saying only that he has “concepts of a plan.” But Vance has said Republicans were interested in a “deregulatory” agenda that would “promote more choice in our health care system and not have a one-size-fits-all approach that puts a lot of people into the same insurance pools.”

That’s important, because talking about “personalizing” health insurance (what Cotton said) through a “deregulatory” agenda to avoid putting “people into the same insurance pools” (what Vance said) is how Republicans have long described their health care agenda, which seeks to weaken or undo insurance rules that the Affordable Care Act put in place.

That agenda seems to be very much alive right now.

What Cotton And Vance Are Talking About

In the old days, beforeObamacare, insurers selling to individuals could charge higher premiums or deny coverage altogether to people with preexisting conditions. They could also sell policies that left out whole categories of standard benefits, like prescription drugs, mental health or rehabilitative care.

These policies were cheap, because they didn’t require insurers to pay out a lot of money. But they frequently left beneficiaries exposed to crushing medical bills when they got sick or injured, plus they were unavailable (or available only with benefit limits and high premiums) to people with preexisting conditions.

In effect, insurers could break up the market based on health status and focus on the lowest-risk customers, making it tough for people with serious medical conditions to find decent coverage.

The Affordable Care Act forced insurers to treat everybody the same ― in other words, to create single, common-risk pools ― by selling policies to anybody regardless of medical risk or condition, and without varying premiums or leaving out core benefits.

These requirements made insurance more expensive, and in some cases a lot more expensive. In order to offset that increase, the Affordable Care Act offers subsidies that can be worth hundreds or frequently thousands of dollars a year, depending on income.

Republicans have long objected to schemes like the Affordable Care Act as wasteful and counterproductive ― and sometimes unjust, because they force people to pay for coverage they might not want or need at the time.

The alternatives Republicans have put forward in the past would restore some of the leeway insurers had to offer cheaper, bare-bones coverage options and to discriminate among customers based on health status.

As for people with preexisting conditions, Republicans have proposed creating special insurance plans they call “high-risk pools” that would serve as insurers of last resort.

Taken together, Republicans say, these steps would make for a more efficient health care market with more options.

Democrats disagree, noting that many states operated high-risk pools like the ones Republicans describe. Those pools were famously underfunded, leading to high costs for beneficiaries and long waiting lists.

Democrats go on to say that Republican promises to take care of people with preexisting conditions are suspect when Republicans want to use their health care agenda as a way to cut spending, in order to finance tax cuts that primarily benefit the wealthy.

What Couldn’t Happen And What Could

Republicans trying to push through changes to the Affordable Care Act would face significant obstacles even if they control both chambers of Congress and Trump returns to the White House.

Procedurally, the rules for the budget reconciliation process make it difficult to include regulatory changes. Politically, the Affordable Care Act is popular and efforts to weaken its insurance rules are unpopular, according to polls.

Plenty of Republicans now in Congress remember how the 2017 repeal effort provoked a backlash, which in turn contributed to their electoral defeats in 2018 and 2020.

But Republican leaders learned a lot in that effort, including how to write reforms that would weaken Affordable Care Act insurance rules while staying within the constraints of reconciliation’s parliamentary rules.

And Republicans seem intent on doing what they can to present their agenda as protecting people with pre-existing conditions ― in part, by promoting their ideas with words like “personalization” that Cotton used on Tuesday night.

Whether that’s convincing to voters could help determine just what happens in November.