The Republican victories in last week's election have ignited a renewed battle over health care reform, with Republican leaders declaring they will to bring efforts to repeal the bill, passed earlier this year.
But how much change could the new Congress actually bring to the reform bill?
Republicans don't have the votes to repeal the bill in its entirety, experts say. A repeal would almost certainly be vetoed by President Obama, and it's not clear that Republicans could muster the two-thirds majority they would need in both houses of Congress to override this veto, said Janet Coffman, a professor at the University of California, San Francisco, who researches health policy. (After Tuesday's election, the Republicans have a majority in the House, but not the Senate.)
But the GOP could block implementation of the health care reform bill through another route — by preventing federal agencies from receiving the funds they would need to carry out some of the bill's provisions.
“What we'll see is a lot of fights over the bill, that will come wrapped as fights over the budget, going forward,” said Joseph Newhouse, a professor of health policy and management at Harvard University.
Many of the bill's provisions require yearly funding appropriations from Congress, Coffman said, and these are the pieces most likely to be affected by last Tuesday's results.
For instance, as was reported in the New York Times on Sunday, Republicans have said they will try to reduce appropriations to the Internal Revenue Service so the agency would not have the resources to implement the so-called individual mandate, the part of the bill that requires most individuals to show proof of health insurance, or face tax penalties, Coffman said.
Republicans could also thwart funds for expansion of the health care work force, an action that will likely be necessary as demand for care increases, she said.
And they could limit money to the Health and Human Services Department, which oversees much of the writing of the regulations for the bill's various provisions, she said.
At this point, it's not clear whether Republicans will try to target specific aspects of the bill, or simply try to cut funds across the board.
Funding for programs such as Medicare and Medicaid are not likely to be affected, Coffman said. Funding for these programs is automatically based on the number of people who qualify for them, and so as enrollment expands, so do expenditures, she said.
The election of many new Republican governors could influence implementation of the bill at the state level.
The states have a lot of responsibility when it comes to establishing the so-called health insurance exchanges — systems that would allow people who don't meet the requirements for Medicare or Medicaid, and can't get health insurance through their employer, to chose an insurance plan from a list of participating providers.
A state could refuse to operate a health insurance exchange, but then the federal government will operate it instead, Newhouse said. And while governors could potentially tinker with the rules of exchanges, “I don’t see that it's in the interest of the state to have an exchange that functions badly,” Newhouse said.
But governors could play a role in how quickly the exchanges get off the ground. Coffman noted that some states, including California, are already taking action to establish the exchanges.
“Whereas in other states, it looks like the state is not going to be particularly proactive at all, if anything maybe trying to resist it and leaving it up to the feds to develop something,” Coffman said.
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