For the past six years, no law has served as a larger GOP target than the Patient Protection and Affordable Care Act, and the Republican sweep Tuesday of political Washington has imperiled the measure's expansive reach, putting at risk the insurance more than 20 million Americans have gained.
During the final week of his campaign, Republican Donald Trump vowed to repeal the 2010 health care law so quickly that he might summon Congress into a special session to accomplish the task. "We will do it, and we will do it very, very quickly. It is a catastrophe," he said.
Yet shortly after dawn Wednesday, a top Republican Senate spokesman said the chamber had not yet formulated its strategy for the coming session. In recent years, the GOP-led House has voted more than five dozen times to rescind the Affordable Care Act, and Speaker Paul Ryan, R-Wis., returned to that point late Wednesday morning when he described the law as "collapsing under its own weight."
While President Barack Obama has blocked congressional attempts to repeal the statute, "now we have President Trump coming, who is asking us to do this," Ryan said.
The Affordable Care Act's most ardent supporters immediately began a counteroffensive to foment opposition to reversing ways the law has upgraded coverage and provided the first-ever federal subsidies for some middle-class Americans to afford health plans. Families USA, a consumer-health lobby, was organizing a midafternoon call with hundreds of Affordable Care Act advocates from about 40 states to begin mapping a grass-roots campaign.
"The clock is ticking, because Republicans appear to be saying health care is going to be the first item on their list with repeal of the ACA being the banner for that, so we realize this work has got to be done quickly and effectively," said Ron Pollack, Families USA's executive director for three decades. "This will be the most intense fight I remember," he said. "One should never underestimate an extraordinary backlash that occurs when people have something that they really value and it is taken away."
In Arkansas, Gov. Asa Hutchinson said during a news conference Wednesday that the election spelled changes for health care in the state.
"What it means is that the American people expect some change in our health care system from Washington, D.C.," he said. "They've given Congress a Republican House and Senate and a Republican president, who have all indicated they want changes, if not replacement, in terms of the Affordable Care Act."
In the long term, Hutchinson said, Republicans in charge at the federal level would mean more flexibility for states to make changes.
"I expect immediate more flexibility to the states in the granting of waivers and, secondly, we're going to have a longer legislative debate on the future of Affordable Care Act -- how it should be changed, replaced, what it should be replaced with," he said.
In Washington, the new Senate's Republican majority will remain short of the 60 votes needed for a full repeal. But Congress demonstrated in the past year that it could use the upper chamber's reconciliation process -- requiring just 50 votes -- to send a bill undoing major Affordable Care Act elements to the White House. Last winter, Obama vetoed that legislation.
"But President Trump would sign," said Tevi Troy, a critic of the law who is a former deputy health secretary and chief executive of the American Health Policy Institute. "Congress intentionally set it up so they could demonstrate a legislative pathway" to reverse large parts of the law. "It was a strategic move."
Larry Levitt, senior vice president at the Kaiser Family Foundation, was bluntly pessimistic about the law's future. "The ACA as we know it would seem to be toast," he said Wednesday morning. "Repealing Obamacare has been such a mantra for conservatives. ... The difficulty for them comes now in trying to come to some consensus about how to unwind it and what to replace it with.
"I don't think there has been a reversal of any public benefit that would be as large as this," Levitt continued. The only other significant reversal by Congress of a major health care policy -- the expansion of Medicare to include catastrophic coverage -- took place in 1989 before the benefit took effect.
For his part, Trump has said that he favors keeping one key aspect, which has outlawed the old practice by many insurers of refusing to cover people with pre-existing medical problems or charging them more than other customers. But the insurance industry has long said it would have a hard time abiding by this rule unless virtually all Americans are required to have insurance -- a central part of the Affordable Care Act that Trump wants to abolish.
Congressional budget analysts and outside health policy experts have estimated the likely impact of replacing the Affordable Care Act with a series of broad-brush health policies that Trump sketched out in his campaign.
The Congressional Budget Office forecast that, over the coming decade, repealing the law would cause the deficit to grow by $353 billion, while the number of people with insurance would drop by about 24 million.
In the short term, the sudden doubt about the law's future also has the potential to confuse the fourth open-enrollment season for Affordable Cart Act health plans through healthcare.gov and similar state-run insurance marketplaces. The three-month sign-up period began eight days ago at a time of spiking insurance rates and diminished insurance options in many parts of the country.
Obama will pitch Americans to sign up for the program during open enrollment. The president and his allies plan to stress that consumers' contracts with insurers are good through the first year of a Trump presidency. Additional enrollment in the program also would raise the stakes for congressional Republicans as they seek to repeal and replace the law without upsetting their constituents.
Other policy targets
Beyond the Affordable Care Act, Trump has vowed to systematically undo what Obama spent eight years putting in place.
"America had never seen anything like Barack and Michelle Obama racing around the country frenetically on behalf of Hillary Clinton," said historian Douglas Brinkley. Obama "could not have put more energy or oomph into his endorsement speeches for her. But it just wasn't enough."
Now, Obama will struggle to preserve as much of his presidency as he can. He will meet with the president-elect at the White House today and said in a Rose Garden statement on Wednesday that he's ordered his staff to ensure a smooth transition. He said that the "remarkable work" of his administration had left to Trump "a stronger, better country than the one that existed eight years ago."
The president is likely to fast-track consideration of those who came to the United States illegally as children and have sought shelter from deportation under an Obama program.
Obama also will do what he can to lock in his environmental legacy. His aides pushed hard to recruit other countries to join the Paris climate agreement, where nations agreed to limit global warming by reducing carbon emissions. The deal was formally put into effect during an 11-day international conference this week, binding the U.S. to the agreement through most of Trump's first term.
Trump has said he will abandon the accord. He is likely to roll back the president's executive actions limiting U.S. carbon emissions, but other nations -- including large polluters like China and India -- still may abide by their commitments.
Obama also will seek to solidify other foreign-policy accomplishments targeted by Trump on the campaign trail. He'll try to reassure allies who are party to the international agreement limiting Iran's nuclear program, as well as the coalition battling the Islamic State in Iraq and Syria, when he travels to Germany, Greece, and Peru this month.
Still, some of the president's priorities seem unlikely to survive. The Republican made opposition to the Trans-Pacific Partnership -- the centerpiece of Obama's attempted pivot to Asia -- a major plank of his campaign.
"The Constitution gives the president great authority in foreign and defense policy. He will set the tone and he will set the policy," said Nicholas Burns, a former undersecretary of state who's now a professor at Harvard University's Kennedy School of Government.
As president, Trump will have the power to ban immigrants from Muslim countries, bar refugees from Syria or other countries and abrogate international agreements such as the Iran nuclear deal, Burns said. He also can alter the commitments at the core of the NATO alliance and other international coalitions.
Still, Burns added, "There are all sorts of regulators on presidential behaviors. Congress is one, the American people is another, so is the press and the attitude of foreign leaders."
Information for this article was contributed by Amy Goldstein of The Washington Post; by Margaret Talev, Justin Sink, Mike Dorning and Zachary Tracer of Bloomberg News; and by Brian Fanney of the Arkansas Democrat-Gazette.
A Section on 11/10/2016
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