To a roaring crowd at the Fox News Republican presidential debate last January, Texas Senator Ted Cruz vowed to "repeal every word" of Obamacare.
Though Cruz ultimately lost the presidential nomination to Donald Trump, the man then considered the underdog, the significance of Cruz’s sentiment was not lost on the American people.
Forty-seven percent of voting Americans, and 83% of those who voted for Trump, think the 2010 federal health care law “went too far,” according to Fox News exit polls on Election Day.
Former NYC Mayor Rudy Giuliani, who is reportedly being considered for a top position in a Trump administration as either Attorney General or Secretary of State, went so far as to say Obamacare is what ultimately gave the businessman the edge over Hillary Clinton on November 8.
“Being part of the campaign, we put [Obamacare] up front in all of Donald Trump’s speeches for the last two or three weeks...That seems to me to be the thing that moved the votes,” he said Sunday in an interview on "This Week with George Stephanopoulos."
Trump has repeatedly made the promise to “repeal and replace” the health care law, and now that he has won the citizens’ mandate, his supporters are expecting him to fulfill that promise—and fast.
Late Friday, Trump announced during an interview with the Wall Street Journal he will make health care a priority, though he is not opposed to keeping parts of the Affordable Care Act intact, including coverage for pre-existing conditions and allowing children to remain under the parents’ plans until the age of 26. This is a far cry from Cruz’s battle call to repeal every word of the law.
Should Trump supporters be worried about the President-elect softening his stance?
The answer is yes, according to Michael Cannon, the Cato Institute’s director of health policy studies.
"Trump basically endorsed keeping Obamacare's central and most harmful provision," he told FOXBusiness.com. "If he sticks to that position, it means he has abandoned repeal. His base will interpret that as complete acquiescence and conclude Trump is no better than the rest in Washington."
On the other hand, unraveling President Obama’s signature domestic policy achievement may not be as easy as the businessman’s supporters believe, even with single party control over the legislative and executive branches.
“The Republican base that got Donald Trump into the White House may be in for a rude awakening. Screaming ‘repeal it’ at a rally is easy. Actually crafting hundreds of pages of legislation that clears four to five Congressional committees, the best-funded lobbying groups in Washington, and manages to secure 218 votes in a very fractured House majority is much, much tougher,” Adam Beck, Assistant Professor of Health Insurance at The American College of Financial Services, told FOXBusiness.com.
There are two ways President-elect Trump can go about repealing the Affordable Care Act, though neither of them will be quick nor easy.
The Republicans do not have a filibuster-proof majority in the Senate, meaning they would need to swing eight to nine votes from the Democratic side in order to pass legislation. That is unless, as the Democrats infamously did in 2010, the Trump administration rams a bill through Congress with no approval from the other side of the aisle.
“It is conceivable they could do this on a straight party-line vote, hold the House [caucus] together. You have to nuke the filibuster in the Senate, and just go straight party-line all the way,” Paul Howard, senior fellow and director of health policy at the Manhattan Institute, told FOXBusiness.com.
Though as President Obama found out that can be an unpopular option. Merely six years after his groundbreaking legislation was enacted, it became the rallying cry for the opposition party, possibly even catapulting a political newcomer into the Oval Office.
The other option is reconciliation. Reconciliation is a legislative process allowing certain matters to be expedited by forbidding a filibuster, which means the Senate would only need 51 votes for approval.
However the scope of this process is limited to assessing certain tax, spending and budget measures.
As it pertains to the healthcare law, this means “anything tax-related” could be addressed, according to Beck.
“This could be a January 21 or January 22 initiative…they will be able to repeal anything that they can put through reconciliation,” Beck said. “The individual mandate, which is essentially a tax provision. That’s going to be gone. The employer mandate, gone. The tax subsidies that fund the exchange are going to be gone.”
Because of the promises Donald Trump has made to his supporters, Beck believes he will be under “a ton of political pressure to get the repeal part of the Affordable Care Act through right away,” which could give way to “a lot of chaos.”
While Trump’s administration may be able to begin the repeal process immediately, the replace part will be a little more difficult especially since they have yet to unite behind a coherent replacement plan. Trump has outlined some traditional Republican bullet points such as HSA’s, purchasing insurance across state lines and reestablishing high-risk pools; far from a comprehensive alternate policy proposal.
Another potential hurdle for the Trump administration: Time. Health care reform was the Democrats’ seminal policy objective for decades, and it took them equally as long to pass something that is now facing repeal.
“The real challenge [will be] finding something the Republican coalition is going to coalesce around that fulfills their promise both to repeal and replace, and finding something that can actually pass the Senate,” Howard said.
However, as Howard pointed out, philosophical splits run deep in the GOP, which will make it harder for the Republicans to coalesce around a singular plan while holding the caucus together in the House.
Aside from simply getting the Republicans to rally around one common health care proposal, a bigger challenge could be getting leaders from across the aisle to step up to the negotiating table.
“The $64,000 question is what is the Democratic calculus right now? Is it to come to the table and deal? Or do you say ‘this is President Obama’s signature domestic policy achievement, it is incredibly popular on the left and there’s a lot of discontent here.’ So does the Warren, Sanders wing of the party go to Chuck Schumer and say we're not compromising on anything?” Howard asked.
It took years to get Obamacare up and running and now Trump wants to upend the certainties consumers, health care providers and insurers were finally coming to terms with.
“We don’t know what to expect and that can create a lot of disruption,” Howard warned.