Congress is back in session on Tuesday, and leaders of both houses say their first order of business will be to repeal Obamacare.
If they do that, it will be a slap in the face to President Obama just three weeks before he leaves the White House. The Affordable Care is the outgoing president's signature achievement, marked by an elaborate signing ceremony in March 2010 at the White House, with lofty speeches from the vice president and Obama himself.
"Today, after almost a century of trying, today after over a year of debate, today, after all the votes have been tallied, health insurance reform becomes law in the United States of America," Obama said that day, to long applause from the assembled crowd.
And Joe Biden famously leaned over to remind the president that it was "a big f****** deal."
But Republicans have been vowing to repeal the law since the day it passed, and they'll soon have a sympathetic president in the White House to sign whatever bill they send him.
"We will repeal the disaster known as Obamacare and create new health care, all sorts of reforms that work for you and your family," President-elect Donald Trump vowed last month in Orlando.
That new health care plan hasn't been fleshed out yet by Trump or his allies in Congress. So they say they'll vote to get rid of Obamacare, but delay its demise until they come up with a replacement that will cover the millions of people who have insurance thanks to the law.
Insurance companies and health care analysts are worried.
"I don't see how you talk to any [insurance] carrier and give them any desire to hang around to see what they replace it with," says Dr. Kavita Patel, an internist at Johns Hopkins University Hospital and senior fellow at the Brookings Institution. "Why would you stick around for that?"
Patel worked in the White House and helped create the Affordable Care Act. But she's not alone in her concern.
Last month the health insurance trade group America's Health Insurance Plans sent a letter to lawmakers asking them to keep in place many of the financial incentives that are central to the law — including subsidies for patients to help them buy insurance and cover copayments, and a provision that eliminates some taxes on insurers.
Still, Republicans appear determined to move ahead with the vote as soon as this week.
Democrats rammed the Affordable Care Act through Congress in 2010 with no Republican support.
It was a huge, complicated law and, like most legislation, it was flawed. Over the subsequent six years, Republicans, who were angry at the way the Affordable Care Act was passed, refused to cooperate in any actions that would be seen as helping it succeed. Instead, they promised in speeches and television interviews to repeal it entirely. In fact, the House has voted more than 60 times over the years to do just that.
"There's no getting around the fact that lots of Republicans campaigned hard against the ACA and a lot of them won, including the person at the top of the ticket," says James Capretta, a scholar at the conservative American Enterprise Institute.
But even with control of both chambers of Congress and with Trump in the White House, Republicans can't simply repeal Obamacare. They would need the help of at least a handful of Democrats to overcome a filibuster.
Democrats can't, however, filibuster budget bills. So Republican leaders have decided to defund Obamacare, eliminating the tax penalties for those who don't buy insurance and the subsidies to help people pay their premiums. Essentially, that guts the law's main elements.
The problem for Republicans is that today, an estimated 20 million people get their insurance through Obamacare. About 10 million buy policies through the exchanges set up by state and federal governments, and most of those patients get subsidies to help pay the premiums.
And millions more are covered because the law allows states to expand the number of people who are eligible for Medicaid, the health insurance program for the poor.
So people who had pre-existing conditions that shut them out of the insurance market before the ACA passed, or people who had reached insurer-imposed lifetime benefit limits, generally like the law.
But, then there are people like Will Denecke, who is mad because his insurance costs have gone up since Obamacare passed. Before the law was enacted, he spent about $340 a month on health insurance.
"Incredibly, we got a notice from my health care company, Moda, which has been having financial problems, that my premium was going up to $930," he said last October.
He's a self-employed urban planning consultant in Portland, Ore., and, unlike most people in Obamacare, he makes too much money to qualify for government subsidies.
"I've had health insurance my whole life, but it's just offensive in principle to think of spending $1,000 a month on health care insurance when there is a good chance I won't need it," he said.
He was considering just letting his coverage lapse.
And, on the other side, you've got people like Leigh Kvetko of Dallas. She takes 10 medications every day because she's had two organ transplant procedures, and the drugs are part of her daily regimen to survive. After Obamacare passed, she was able quit her job at a big company and start a business with her husband, because she could finally get individual insurance.
"This particular plan, the fact that they cannot discriminate against me because of how I was born, was a lifesaver, literally," she says.
House Ways and Means Committee Chairman Kevin Brady told the Washington Times last month that consumers needn't worry. "We can assure the American public that the plan they're in right now, the Obamacare plans, will not end on Jan. 20, that we're going to be prepared and ready with new options tailored for them," he said.
RACHEL MARTIN, HOST:
Today in Your Health, the future of the Affordable Care Act. On Wednesday, President Obama will meet with congressional Democrats about how to protect the health care reform plan that bears his name. Republican leaders have said they'll repeal Obamacare as soon as they take the reins in Washington. My co-host David Greene spoke with NPR health policy correspondent Alison Kodjak about the longstanding tension over this legislation.
ALISON KODJAK, BYLINE: In 2010, the Democrats kind of ran through this law without any Republican support. It was huge, it was complicated, thousands of pages long and ever since, Republicans have been pretty mad about how it passed. And they've refused to help fix it, and, instead, they've just promised over and over again to repeal. And in fact, the House has already voted more than 60 times to do just that over the years.
DAVID GREENE, BYLINE: And now they have - they'll have a Republican president, both houses in Republican control. Looks like it can happen. What exactly does it mean to repeal?
KODJAK: Well, they can't really repeal it outright because the Democrats in the Senate can filibuster that and block it, but Democrats can't filibuster anything that has to do with the budget. So what the Republicans probably will do is eliminate the financial parts of the law, the tax and budget items.
But that means they'll eliminate the penalty for people who don't buy health insurance, and they'll eliminate the subsidies that help people pay for insurance under the law. That's really the core of the Affordable Care Act. So what's not clear is how quickly they're going to cut off the money. They're trying to come up with a replacement plan, and so they may delay that for months or even years.
GREENE: So lack of clarity, delays could mean a lot of people left in limbo, I imagine.
KODJAK: Millions. Right now, the estimate's about 20 million people get their insurance through Obamacare one way or another. You've got about 10 million people who buy plans through the exchanges that have been set up by the federal and state governments and then there are millions more who have insurance because of the expansion of Medicaid under the law. About 31 states and D.C. have expanded Medicaid to people who have a little bit more money just over the poverty line. And a lot of that is in the Affordable Care Act and could be reversed as well.
GREENE: Democrats have made the charge that people could be cut off if Republicans act very boldly and very quickly. Is that possible? Could Republicans literally cut people off who would get insurance under this?
KODJAK: Well, I don't think that they want to. They have said over and over again - Republican leaders - that they have no intention of just throwing people off their insurance policies. But there's a lot that they have to consider. Before the Affordable Care Act, people with existing medical conditions - they often couldn't get any insurance or they were very much priced out of the market. And there are also a whole group of people who had lifetime limits like a million dollars. And when you have a severe illness, you can reach that limit. So there's this whole slew of people who did not have insurance, and they're pretty happy with Obamacare, that they can get coverage now. But then there are other people like Will Denecke. I talked to him last October just before he was going to start shopping for insurance for this year, and he was pretty mad because his costs were rising.
WILL DENECKE: Incredibly, we got a notice from our health care company, Moda, which has had financial problems saying that my premium was going up to $930.
KODJAK: So Denecke's self-employed and unlike most people on Obamacare, he makes too much money to qualify for government subsidies. So before the ACA, he paid about $340 a month for insurance, but that's all changed.
DENECKE: I've had health insurance my whole life, but it's just offensive, you know, in principle to think about spending a thousand dollars a month for health care insurance. I just don't make enough to, you know - to pay that kind of percent of my income on health insurance.
KODJAK: But on the other side of the equation, you have people like Leigh Kvetko. She lives in Texas, and she takes about 10 medications every day because she's had two organ transplants. And after Obamacare passed, she was able to quit her job at a big company, start her own business because she could finally get her own insurance.
LEIGH KVETKO: This particular plan - the fact that they cannot discriminate against me because of how I was born was a lifesaver, literally.
GREENE: OK. So Alison Kodjak, that voice right there is someone who really relied on this law because she had preexisting conditions, she could make a big change, start her own company and she would still get insurance. She wouldn't lose it.
KODJAK: Exactly. And that's who the law was really directed at in the first place, people like her.
GREENE: OK. So some of the things you've talked about - Congress could come in, they could defund a lot of parts of this law, the president - you know, President Trump once he comes in will probably sign that. What happens next?
KODJAK: Well, if they vote to defund, all the money could go away to implement and support the law. But some elements stay in place, including the requirement that insurance companies cover people who have ongoing medical conditions, people like Leigh Kvetko. And Trump has said over and over again that he wants to keep that provision because it's very popular. Here he is with Lesley Stahl on "60 Minutes" just after the election.
(SOUNDBITE OF TV SHOW, "60 MINUTES")
LESLEY STAHL: When you replace it, are you going to make sure that people with pre-conditions are still covered?
DONALD TRUMP: Yes. Because it happens to be one of the strongest assets.
STAHL: You're going to keep that?
TRUMP: Also with the children living with their parents for an extended period, we're...
STAHL: You're going to keep that?
TRUMP: ...Very much try and keep that in.
KODJAK: The problem with that is that some experts warn that the individual insurance market could collapse altogether if that part of the law is preserved, but young, healthy people stop paying for insurance 'cause it gets too expensive.
GREENE: Because there'd be less money in the system to actually support the people who need the insurance.
GREENE: That's the argument that Democrats are making.
GREENE: So do the Republicans have kind of a broad plan that would give us some idea of, you know, something comprehensive that would be replacing Obamacare?
KODJAK: Well, so what they have is they don't have legislative language. There's a lot of ideas out there. Various members of Congress have put out proposals, but they don't have a definitive plan which is where this talk of delay comes in. They may vote to repeal, but not cut off the money immediately while they come up with their replacement plan.
But included in those ideas there are some general principles. One is that instead of requiring people to buy insurance which is really unpopular, they would instead create incentives for people to buy insurance by offering tax credits toward your insurance premiums. But there's not a definitive proposal out there. And Republicans are talking about perhaps waiting years before they find a replacement to the Affordable Care Act.
GREENE: All of which is to say you're going to be a very busy reporter covering all of this in this year and the coming year.
KODJAK: I'm sure I will be (laughter).
GREENE: All right. That's NPR's health policy correspondent Alison Kodjak. Thanks, Alison.
KODJAK: Thanks, David. Transcript provided by NPR, Copyright NPR.