Now some fellow Republicans are throwing obstacles in their path. Five members of the Senate majority have introduced an amendment that would effectively delay a vote on repeal until March, while a few others have suggested that the ACA should not be repealed until a replacement plan is ready to be enacted in its place. On the House side, members of the arch-conservative Freedom Caucus have also threatened to oppose the Republican leadership's budget resolution when it comes up for a vote later this week unless they receive more specific information about the nature and timetable of ACA repeal-and-replace legislation. (Passage of the budget resolution through both chambers is a necessary first step to use the filibuster-proof reconciliation process to repeal provisions of the ACA.)
We might expect politicians to get a case of political cold feet about the risk of voting to upend the entire health care industry in potentially unpredictable ways, as well as the potential fallout of revoking public benefits from millions of citizens. Otherwise staunch ideological conservatives like Tom Cotton of Arkansas and Rand Paul of Kentucky have objected to the leadership's fast-track approach; it's hardly a coincidence that both senators represent states that have experienced a significant decline in their populations of uninsured residents under the ACA. Republican senator Shelley Moore Capito of West Virginia, another state with many ACA beneficiaries, even endorsed the idea that any replacement health care plan should cover more citizens than Obamacare does—a telling concession to the complex political considerations that Republicans now face as they try to square their small-government philosophical predispositions with their electoral survival instincts.
But that can't be the whole story. After all, the House Freedom Caucus is famous for claiming unmatched devotion to conservative principle and for constantly criticizing the Republican leadership from the ideological right. It's hard to envision its members going wobbly on ACA repeal before Trump's term has even begun—especially since they uniformly represent deep red districts with little chance of serious challenge from the Democratic opposition.
What's also going on here is the preliminary round of what may prove to be a significant internal battle within the Republican Party over the legislative specifics of repeal-and-replace. The absence of a party-endorsed replacement plan for Obamacare over the seven years and counting since one was promised by the congressional GOP reflected the difficulties that party leaders faced in uniting Republican members around a single alternative—but this policy void must be filled now that repeal-and-replace has evolved from catchy slogan to legislative agenda. Various key actors within the party will now seek to maximize their leverage over the policy-making process, which often involves threatening or even imposing procedural obstacles to the passage of reform unless and until they gain the opportunity to exert influence over its shape. The Freedom Caucus is not averse to making common cause with Democrats to outvote its own party leadership on the floor of the House, while the small group of Republican senators currently making trouble for McConnell similarly constitute a strategically pivotal voting bloc, given the close margin of party control in the chamber.
Jonathan Chait and Brian Beutler argue that the public maneuvering of the past few days indicates that there probably aren't 51 votes in the Senate to repeal and replace the ACA in anything other than cosmetic fashion. That's true for the moment, though it would be premature to conclude that repeal is doomed to failure. At this stage, it's likely that the senators currently wandering off the leadership reservation are raising public doubts in order to assert control over the reform process rather than to derail it entirely. Tellingly, one of the troublemakers is Lamar Alexander of Tennessee, chair of the Senate Health, Education, Labor and Pensions Committee, who might well be expected to seize an opportunity to establish his own independent authority over both the substantive and procedural content of reform. The relatively pragmatic and policy-minded Alexander will be in the position to argue that the only bill with a prayer of passing the Senate will be one that he writes himself, and that his committee—not the House leadership or the hard-line Tea Party bloc—should therefore take the lead in developing the elusive Republican alternative reform package.
Such claims will not sit well with the Freedom Caucus or other Republican factions, which will use similar tactics in order to seek control of the process for themselves. This fight could get messy, and the current GOP congressional leadership does not have an impressive record of successfully uniting its members in support of ambitious, complex, politically controversial policy initiatives. It's not difficult to imagine large-scale reform ultimately foundering due to unresolvable differences between the House and Senate, or between party pragmatists and conservative purists. Over the past few weeks, as the reality of imminent one-party rule has begun to settle upon Washington, a number of Republican officeholders have begun to acknowledge that "repeal-and-replace" is much more complicated in practice than it might have initially appeared.
However, it's very difficult to gauge the prospects for ACA repeal without further insight into the intentions of the new president. Donald Trump holds unique political influence within his party that he could exploit to crack some heads on Capitol Hill and get a deal done (what Republican member of Congress would want to end up on the wrong side of a presidential Twitter rant?). If Trump identifies ACA replacement as a top priority and devotes the necessary attention and energy to the issue during the first months of his presidency, it would be hard to deny the possibility of legislative success—even if it were followed by significant policy complications that would then invite a popular backlash against Republican politicians.
If he really wants fundamental reform to pass, however, Trump will have to assure congressional Republicans that he won't sell them out. There will be some unavoidable political costs to a true repeal-and-replace approach, and GOP members will need Trump to provide them with political cover by sharing these costs. Right now, they are probably unsure of his loyalty—and, based on his past behavior, they have reason to be.
What happens when citizens, some of them Trump supporters, begin to complain that he and his party are messing around with their health insurance? Does Trump take responsibility for the policy implications of repeal-and-replace, or does he respond to blowback by disavowing the Republican replacement plan and blaming Congress for any unpopular consequences? It would truly be a political nightmare for congressional Republicans if they were to cast tough votes to repeal the ACA only to have a president of their own party join the chorus of critics.
So far, it doesn't seem as if the incoming president has communicated to congressional Republicans that health care reform is in fact his primary legislative objective, or that he will stand with them politically over the months and even years that will be necessary to see it through to completion. One senator even pleaded with Trump this week to clarify his health care ideas via Twitter—which, though it inspired some mockery, would at least have the advantage of publicly committing the new administration to some specific choices and thus send valuable signals to the Hill about how best to proceed.
ACA repeal isn't dead, but it faces little chance of surviving the arduous legislative process without significant presidential investment. Unless Trump is willing to publicly and privately devote himself to the cause (and assume the corresponding political risks), Congress is unlikely to do the heavy legislative lifting required to enact significant further change to the American health care system. If he wants to claim victory over Obamacare, Trump needs to join the fight.
ACA repeal isn't dead, but it faces little chance of surviving the arduous legislative process without significant presidential investment. Unless Trump is willing to publicly and privately devote himself to the cause (and assume the corresponding political risks), Congress is unlikely to do the heavy legislative lifting required to enact significant further change to the American health care system. If he wants to claim victory over Obamacare, Trump needs to join the fight.