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Social welfare legislation is inherently political, and the absence of bipartisan support during passage of the ACA hardened party-line opinions. The Senate also used reconciliation to adopt the ACA, further fueling Republican discontent. Although the public approves of individual provisions in the ACA, the law as a whole generally remains unpopular. If “repeal and replace” passed on a party-line basis, it could generate the same dynamic that undermined the ACA. There are also legal impediments to using the reconciliation tool for nonbudgetary aspects of the reform package. Moreover, if Congress were to remove subsidies or benefits that individuals now enjoy, it could provoke a political backlash. (Lawrence O. Gostin, David A. Hyman and Peter D. Jacobson, 11/28)

On November 8, 2016, Republicans won the presidency and retained control of the US House and Senate in Congress. The composition of the Senate shift will profoundly affect the passage of new legislation. With only 52 Republicans in the Senate, the Republican Senate leadership will have to ensure that all Republicans support any legislation because a few defections on an issue could push them into a minority position. More challenging is that except for budget-related legislation, which can pass with only a simple majority, other legislation, including much of an Affordable Care Act (ACA) replacement bill, will require the support of 60 votes in the Senate to circumvent a filibuster. (Gail R. Wilensky, 11/28)

To his credit, the president-elect has said he intends to keep the popular provisions of the ACA, while amending the law to reduce the cost of the program to those who are participating as well as to taxpayers. But as most health policy experts agree, this will be nearly impossible to achieve without a mandate to ensure a balance risk pool. As the incoming administration seeks solutions, it is critical that they and members of Congress avoid the “cut and shift” tendency that has often been employed in similar circumstances in the past. Rather than shifting federal health costs on to the states, to businesses, to health stakeholders or to beneficiaries, policymakers must look for ways to redesign and improve the individual market place to ensure longer-term improvements in both quality and lower cost. (Tom Daschle, 11/29)

In the days since the election, Republicans have realized that they are in a tight spot on Obamacare. They seem to be lurching toward a strategy that will make it tighter. Republicans have vowed over and over again to repeal and replace the health-care law, but they do not yet have a detailed plan or the votes to enact it. Democrats, meanwhile, remain committed to the law, and there will be at least 48 of them in the new Senate. Unless eight of them defect, they have enough votes to filibuster Republican bills to undo it. Republicans probably do not have the votes to abolish the filibuster. (Ramesh Ponnuru, 11/28)

Republicans have said that Congress could vote early next year to repeal the Affordable Care Act but delay the actual end of the law for a year or two. In theory, that would allow lawmakers to come up with a workable replacement while putting off the consequences of repeal. But any vote to repeal the law would almost certainly cause insurers — which know they won’t be able to depend on the federal government in the future — to start pulling their plans from the online marketplaces for 2018 coverage, kicking millions off coverage. State and local governments will have to start planning to increase spending on public hospitals and charity medical care. Consider this: Uncompensated care at hospitals declined by $7.4 billion in 2014 after most major provisions of the law kicked in, according to the Department of Health and Human Services. Those costs would most likely go right back up. (11/28)

As I’ve written before, while more Americans are insured, many are still underinsured — meaning that they are exposed to significant financial risk from out-of-pocket payments. Reducing out-of-pocket spending, however, will require some trade-offs. No easy solution exists, but there are examples out there worthy of consideration. (Aaron E. Carroll, 11/28)

We’ve always known that there was some “woodwork effect,” in which people who were already eligible signed up because of some combination of easier signup procedures and the heightened publicity that surrounded Obamacare’s passage and implementation. But these are  huge numbers; the woodwork effect is more than twice as large as the number of people who became eligible for Medicaid thanks to Obamacare’s more generous criteria. This suggests the possibility that the plurality of people who gained insurance thanks to the law technically didn’t need a new program to become insured; all they needed to do was to sign up for public insurance they already qualified for. (Megan McArdle, 11/28)

To encourage states to properly manage Medicaid spending, Congress should replace the federal matching scheme with a different funding mechanism. Earlier this year, House Republicans suggested moving to either block grants or per capita allotments. A block grant is a fixed sum of money allocated to each state to support its Medicaid spending, while a per capita allotment would provide states a fixed amount of funding per Medicaid beneficiary. In either case, annual federal funding would grow at a slower rate than it does now, but states would have much more flexibility in the way they use federal Medicaid grants, enabling them to provide services in a more cost-effective manner. (Marc Joffe, 11/28)

Dean Angstadt required a lot of convincing to sign up for Obamacare. The Pennsylvania logger had heard a lot of bad things about the president’s signature domestic initiative. Over a period of months, however, a friend of Angstadt’s — Bob Leinhauser, who’d worked for 27 years at Montgomery County’s fire and rescue department — prevailed upon him to sign up, given the stakes and all. “I was going to die,” he told this blog back in April 2014. “I was preparing myself.” He desperately needed heart-valve replacement surgery, a procedure he’d been putting off because of his finances. Thanks to Leinhauser’s prodding, he paid a minimal amount for a policy that covered a surgery he never could have paid for. (Eric Wemple, 11/28)

Now that the elections are over, it’s just the beginning of what could be a troubling reform process to the Affordable Care Act, particularly for those with pre-existing conditions. Whether significant changes to the Affordable Care Act are on the horizon in the very near future remains to be seen, but people with pre-existing conditions will be paying close attention in the coming weeks as a new administration takes over governing entities. (Paul Gileno, 11/29)

While sanctuary policies vary, these cities generally limit how much local law enforcement cooperates with federal immigration officials. Leaders in Sacramento, San Francisco and other cities have vowed to fight federal attempts to deport undocumented immigrants. Ironically, the Republican assault on Obamacare may prove to be the basis that courts use to reject efforts to defund sanctuary cities. (Bill Ong Hing, 11/28)