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What's Next: How Republicans Plan to Roll Back the Health Care Reform Law

House vote to repeal was only the first step

The House Republicans' vote to repeal the nation's new health care reform law Wednesday was symbolic, but it did in fact signal the party's very real determination to overturn the law and block its implementation.

HCR Battle

— iStockphoto and Dreamstime

"We will do everything we can to delay and defund provisions of the [law] so we can get some discussion going on how to replace it," House Majority Leader Eric Cantor (R-Va.) told reporters Tuesday.

Democrats meanwhile used the threat of repeal as an opportunity to promote new consumer benefits of the massive Affordable Care Act — such as abolishing exclusions of coverage for preexisting medical conditions in the individual insurance market, closing the Medicare coverage gap (the "doughnut hole") for prescription drugs and allowing young adults under age 26 to stay on their parents' insurance. "The debate … gives us a chance to remind people what it is that's at stake," Health and Human Services Secretary Kathleen Sebelius told reporters Wednesday, and "why we can't go back to where we were."

Public opinion on the law is still deeply divided, with 26 percent favoring total repeal, 25 percent wanting partial repeal, 21 percent preferring the law left as it is, and 20 percent wanting it expanded, according to a recent poll by the Kaiser Family Foundation.

These are some of the arenas in which the renewed battle over health care reform will be played out:

Revoking the individual mandate

So far, 25 states have joined Florida's lawsuit challenging the constitutionality of the law, mainly its requirement that people must buy health insurance or face a penalty or tax. In three other lawsuits, two federal judges have ruled that this requirement, known as the individual mandate, is constitutional, and the third held that it is not. All are expected to be decided finally by the Supreme Court.

If the court throws out the mandate, the law's core principle of having a national pool of insured people to bring down costs would be undermined. Insurance companies were willing to insure those with preexisting conditions in return for an expanded national pool that includes millions of new healthy customers. One alternative to the mandate, now under discussion, is to encourage people to buy insurance early by making it more expensive for those who delay, in much the same way that Medicare levies a permanent premium surcharge on those who sign up late.

Starving the law of funds

The law provides around $1 million to each state to set up the insurance exchanges that are another key plank of the law. Starting in 2014, they would offer a menu of private health plans to people without employer insurance or in small businesses, with premium subsidies for those with incomes under a certain level. If the House appropriations process cuts off this funding, as Republican members have threatened, it would deal a mortal blow to the legislation.

But experts say that's not immediately possible — these funds are already built into the law and would need another act of Congress to remove. Which leaves many state governors who oppose the law in something of a quandary: If they decline the funding, the federal government has the authority to establish the exchanges itself by default. But some other existing areas of the law are vulnerable to defunding, such as efforts to educate consumers about the exchanges and billions of dollars needed for implementation of its many provisions.

Arguments over the deficit

Democrats in Congress and the White House received an unexpected boost to their support for the law when the Congressional Budget Office — a nonpartisan body that estimates the cost of legislation — came out with a new analysis earlier this month. It said that repealing the law would increase the national deficit by $230 billion from 2012 to 2021 while leaving an additional 32 million people uninsured.

The new speaker of the House, John Boehner (R-Ohio), rejected the CBO's conclusions, telling reporters: "I do not believe that repealing the job-killing health care law will increase the deficit."

Republican leaders had cited the CBO as their source for claiming that the new law would result in 650,000 lost jobs. But what the CBO actually said was that the impact on labor would be small, according to a fact check by the Associated Press. "Most of it would come from people who no longer have to work, or can downshift to less demanding employment, because insurance would be available outside the job," it concluded.

This deficit debate will continue as each side tries to sway public opinion to help further its aims — Democrats to preserve the law, the Republicans to amend and recast it.

Patricia Barry is a senior editor with the AARP Bulletin.

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