For some Republicans, obliteration of Obamacare can’t come soon enough.

Others want a gradual phaseout, fearing both the political and practical consequences of throwing 20 million Americans off their health plans virtually overnight.


And President-elect Donald Trump, who vowed to repeal and replace “the disastrous” Obamacare, sent mixed signals Friday about how he will proceed. For the first time, he told The Wall Street Journal he might preserve the popular prohibition against insurers denying coverage because of preexisting conditions and another provision allowing young people to stay on their parents’ insurance plans to age 26. Trump said President Barack Obama personally asked him to consider it.

“Either Obamacare will be amended, or repealed and replaced,” Trump said.

Trump’s statement heaped new confusion on how the GOP will move forward with its campaign pledge to repeal and replace Obamacare. A party rift was already emerging between lawmakers and advocacy groups who want a slow and orderly transition to give notice to the millions now covered — and those who want to repeal the entire law within minutes of Trump’s inauguration. And that’s only one of the disagreements as lawmakers, Trump’s transition team and conservative groups wade through the complicated policy and political ramifications of how to repeal Obamacare and how to replace it.

For six years, Republicans have sought every possible way to kill the landmark health law — bringing failed lawsuits and waging unwinnable legislative fights that a Democratic president could always veto. Now that the stars have aligned to allow them to do it, they can’t agree on how to proceed.

For instance, Heritage Action, which is influential with House conservatives and is also advising the incoming administration, is demanding that Congress prepare a repeal bill that Trump could sign on Inauguration Day. Some conservative lawmakers agree.

“It should crumble immediately because Americans can’t afford it,” said Rep. Andy Harris (R-Md.), a member of the Freedom Caucus who wants to see the individual mandate scrapped right away.

But that demand for immediacy is running up against others who insist on providing those enrolled in Obamacare plans with a transition period before an Obamacare repeal takes effect. They also want to replace it with a new system — one that the GOP hasn’t even agreed upon.

“It’s not going to be easy to fix,” said Rep. Phil Roe (R-Tenn.), an ardent opponent of Obamacare. He pointed out that insurers are already selling 2017 health plans.

“There’s nothing you can do about that,” Roe said. “It’s going to take one to two years to reconstitute a marketplace.”

Republicans leaders are just starting to wade into the mechanics of repealing the law, according to aides on Capitol Hill. Those plans are expected to pick up steam when lawmakers return to Washington next week. An abrupt change would affect not just the people covered, but virtually the entire health care system.

Complicating their discussions is the practical reality that they will have only one shot at passing a health bill using a difficult budget maneuver that prevents a Democratic filibuster.

Republicans favoring a transition period say they want to give Obamacare enrollees plenty of time and notice that their subsidies would go away. Others favor repealing the individual mandate almost immediately and want to push the Trump administration to move as aggressively as possible at undermining the law through regulation.

The quickest thing a GOP administration could do is refuse to pay insurance companies the subsidies they make on behalf of low-income people. Insurers would face insurmountable costs and would be allowed to leave the markets almost immediately.

If Republicans aggressively attack the law through regulation, the law will quickly crumble because insurers will become unstable and customers would lose coverage with little notice. For some in the GOP, that’s the goal. But others fear that would generate backlash.

Trump, meanwhile, did not spell out the details of how he’d guarantee coverage to those with chronic health problems, without making insurance premiums soar. Many Republicans have proposed keeping a modified form of the preexisting condition measure that would protect people as long as they’ve maintained continuous coverage. It was not clear whether Trump wanted to keep the current ACA provision, or adopt the GOP suggestion.

Another point of friction: Some Republicans want to have a replacement ready when the law is repealed, while others are eager to get repeal done regardless of whether a replacement is prepped.

Republicans will work off of a 2015 repeal bill passed under reconciliation, a special budget procedure that would bypass a Democratic filibuster. It is a complicated procedure that allows only some of the major parts of the law to be repealed. In theory, a replacement could be part of that.

But that’s also more difficult than it might appear: The complex budget process means they can’t start the replacement from scratch — they have to work off a part of Obamacare.

“It’s easy to build a ranch on an open lot,” said Sage Eastman, principle at Mehlman Castagnetti Rosen & Thomas and former Republican Ways and Means Committee staffer. “But to convert that into a different style house is different. … It’s often a more complicated effort once you have one structure in place.”

Paul Winfree of the Trump transition team and the Heritage Foundation and Brian Blase of the Mercatus Center argue the new bill should go even further than last year’s reconciliation bill, which passed both chambers of Congress but was vetoed by President Obama.

“Congress should build off last year’s reconciliation bill,” they wrote in a POLITICO opinion piece, arguing that the new bill can repeal all of the health law’s insurance industry reforms. They argue that the 2015 King v. Burwell Supreme Court case — in which the Obama administration argued that all parts of the law are unmistakably linked — proved that the insurance reforms, including the pre-existing conditions and age 26 provisions, are tied to the rest of the law.

There are also questions about whether a replacement to the law can be done at the same time as the repeal through the reconciliation process. Some Republicans are worried about appearing reckless by getting rid of Obamacare without a new system in place, opening themselves up to accusations that they’re canceling consumers’ health plans — a huge vulnerability Democrats faced on late 2013 when some insurance plans were canceled.

“Certainly in the House, they are running for office constantly, only two years to go again,” said Joe Antos, a health care policy expert at the American Enterprise Institute. “Most of them are not going to want campaign ads in two years that say Mr. X or Mrs. X is responsible for throwing 20 million people off health insurance.”

Democrats, for their part, are preparing to do all they can to stop the GOP repeal effort, but they may be able to do little besides remind voters that Republicans are throwing millions off their health care plans.

“If the Democrats want to play politics on this, let’s have at it,” Harris said. “The majority of Americans are with the Republicans to finally make health care affordable.”