If you’re a congressional Republican, you consider Obamacare a “failure”, and “repeal and replace” is your mantra. For all intents and purposes, the party appears to be a united front.

But cracks in that facade were already showing on Wednesday, day two of the 115th Congress, when senators passed a resolution to repeal Barack Obama’s signature healthcare reform, one that sets in motion legislative machinery to end taxes and spending associated with the law. All Republican senators voted in favor, with one exception: Rand Paul.

“If Congress fails to vote on a replacement at the same time as repeal, the repealers risk assuming the blame for the continued unraveling of Obamacare,” Paul wrote in an op-ed before the vote on Wednesday. “For, mark my words, Obamacare will continue to unravel and wreak havoc for years to come.”



Paul warned that keeping popular regulations, such as those requiring insurers to issue policies to the sick, could cause a “mass bankruptcy” of insurance companies. On Wednesday, he explained his vote on the Senate floor. While he said he supported repealing Obamacare, he said the GOP’s current proposal would increase the government’s debt by $9.7tn over the next 10 years. “Is that really what the Republican party represents?” he asked.

Republican senators Lamar Alexander and Susan Collins also voted yes but have previously expressed concerns about the rush to repeal without a replacement plan.

In Tennessee, Alexander’s home state, insurance exchanges are in deep trouble. Just one insurance company covers Tennessee, and that company had to raise premiums significantly in 2017. Still, around 163,000 people purchase insurance through those Obamacare exchanges.

Alexander said he thought the individual mandate, a tax penalty meant to encourage people to buy insurance, should be repealed, but first a replacement for Obamacare needed to be ready.

“There are a number of things that need to be repealed, but I think what we need to focus on first is what would we replace it with,” Alexander told Slate about a week after the election. “And what are the steps that it would take to do that?” Alexander’s comments are significant because he is chair of the Senate’s health, education, labor and pensions committee, one of the committees tasked with developing a repeal plan.

Lamar Alexander voted yes but has previously expressed concerns about the rush to repeal without a replacement plan. Photograph: Reuters

Alexander’s colleague, Collins, of Maine, told the Portland Press Herald a month later that she tended to agree with his “more cautious approach”.

“You can’t just drop insurance for 84,000 people,” Collins said, referring to those who had signed up for health exchange plans in Maine.

Many other Republicans who have spoken in support of repealing Obamacare still face difficult decisions at home. Senator Dean Heller’s home state of Nevada, for example, expanded Medicaid as part of Obamacare and newly insured about 187,000 people. In 2016, another 88,000 people were insured through the state’s insurance exchange, which had one of the smallest average increases in healthcare premium costs in the country at just 6%, or $15.

All of that underscores the problem Republicans are faced with: how to repeal a law that touches nearly every facet of American healthcare, and insures an additional 20 million Americans, without shredding a fragile system.

“Both sides are going to have to grow up, because in sensitive races, voters are going to say: ‘A pox on both your houses,’ and you’re going to see incumbents on both sides lose their seats,” said Joe Antos, a healthcare policy researcher with the conservative American Enterprise Institute.

Americans are covered by a mix of commercial and government healthcare. The largest government healthcare programs cover the elderly (Medicare) and the very poor (Medicaid). About half of Americans get healthcare through their employers, and the rest purchase insurance through state marketplaces.

Though most people think of “Obamacare” as state exchanges where individuals can buy insurance with a subsidy, the law touched many other parts of the American healthcare system.

For example, taxes on the wealthy shored up the Medicare trust fund. The federal government paid for states to expand Medicaid to cover millions of Americans who previously were not poor enough to qualify.

That means Republicans looking to fulfill the seven-year pledge to repeal and replace the law will probably need to strike a whole new grand bargain, as Democrats did to enact the law – one that will eventually require the cooperation of Senate Democrats.

House Republicans are not necessarily immune from political fallout from health law changes either. House Republicans’ willingness to get rid of it and worry about how to replace it later depends on what kind of pressure members may receive from not just residents of their district, but also constituents such as hospitals and doctors.

“I also hear from a lot of House members who have these same kinds of dilemmas, really,” said Grace-Marie Turner, president of the conservative health policy research center the Galen Institute.

“It shows that Obamacare is full of land mines,” she said. “It’s like trying to remodel a house while it’s on a train speeding down the rails at 80 miles per hour. It’s really tough to do.”

Democrats’ loss in the 2010 midterms showed just how difficult healthcare reform can be. Democrats lost more than 50 seats during that cycle, not long after Obama’s health reforms passed. Though the economy was at the top of voters’ minds at the time, exit polls showed voters split on the Affordable Care Act.

The bill that passed Wednesday allows Republicans to start dismantling provisions that impact the federal budget. Using a legislative maneuver called budget reconciliation, the Senate can pass bills with just 51 votes. There are 52 Republicans in the Senate.

But even this may prove unpalatable for some Republicans. For centrists, repealing Obamacare without a replacement, and imperiling the health insurance of hundreds of thousands of constituents, simply may not be worth the political risk. For conservatives, the need to spend money to keep low-income Americans insured could run up again anti-tax ideologies, again imperiling coverage for millions. To change Obamacare’s regulations, provisions that don’t impact the budget, Republicans will likely need to work with Democrats to reach 60 votes.

“This is going to get more and more difficult each step of the way going forward,” said G William Hoagland, a senior vice-president at the Bipartisan Policy Center and a former US Senate staffer.

“Once you put an entitlement out there – and these are entitlements – boy, it’s hard to take them away,” he said. “What you end up with is tinkering at the margin. You say, you’re still going to have the same level of coverage, you’re going to still increase the quality of care, you’re going to decrease the cost – those are the same three principles [as Obamacare’s].”

Because of Obamacare, more than 90% of Americans have health insurance, and state exchanges were busier than ever this fall. But state exchanges are indeed imperiled. More than one-third of counties have only one insurance option. In most places, premiums are rising, though overall healthcare costs have slowed since Obamacare was implemented.

Republicans’ best bet, according to Antos, could be to prop up state exchanges established by Obamacare to prevent commercial insurers from fleeing those markets while a swift replacement is developed.

This could require Republicans to pay insurers millions in “risk corridor” payments, which some of the same Republican lawmakers previously called a “bailout” for the insurance industry. Those payments were established by Obamacare to cover patients that turned out to be sicker than predicted.

“Donald Trump already said he doesn’t want interruption of coverage for people,” Antos said.

“Next year is going to be an issue, and a lot depends on what legislation passes this year. That is really hard to predict right now.”