With polls continuing to show Republican congressional candidates beating their Democratic opponents across the country, Washington’s assorted analysts, pundits and rumor mongers are now firmly of the mind that the GOP will win back the House on November 2, and may have an – albeit lesser – shot of winning the Senate. (My favorite pundit of all – Nate Silver, who writes New York Times’ blog fivethirtyeight – now puts the odds of a GOP House takeover at 72 percent and a Senate takeover at 18 percent.) House Republicans have pledged to repeal and replace the Affordable Care Act (ACA), if they come into power. Everyone who can count to 60 (the number of Senators needed to break a filibuster) knows that a full “repeal and replace” bill will be dead-on-arrival in the Senate. Yet, the threat of repeal and replace has me thinking about how this legislative battle might play out. Mostly, I have questions:

• Would a House Republican majority actually push through a full repeal and replace bill, knowing that the Senate would never pass it? My instinct tells me “yes,” since this has been a top campaign issue. A simple repeal bill would be relatively easy to put together, and if all House Republicans stick together, easy to pass through that chamber. The tougher part is replacing it. If Republicans are serious about going through regular order, this would mean months of committee mark-ups, drafting errors, CBO scores, rallies on the Hill, press conferences, press releases, and the like. Welcome back to 2009. Is this really what the new Republican majority wants to focus on in its first months back?
  
  
• After (or perhaps instead of) that, what specific policies will the GOP go after? Given its unpopularity, I would guess the individual mandate is on the chopping block. Yet, as the insurance industry is quick to note, without the mandate, the other changes in the law (particularly insurance market changes, many of which are already going into effect), would mean skyrocketing premiums. The whole law is tied together by the individual mandate. How does the insurance lobby play in that debate? If Republicans choose to eliminate the mandate, will they also have to get rid of the pre-existing conditions protections, lifetime cap eliminations and other popular insurance market reforms?
  
  
• Will Republicans try to eliminate or reduce the Medicaid expansion? Nearly half of the newly insured will be covered by an expanded Medicaid program. A costly proposition to be sure, but actually less expensive than most other options for covering this population. Can Republicans simply eliminate the expansion and say “sorry” to the 16 million people who are scheduled to be covered in 2014? If not, what is their alternative? Many of the “replacement” ideas included in the GOP pledge have already been scored by the CBO and, while cheaper than the ACA, have been found wanting when it comes to providing actual coverage.
  
  
• How will the White House respond? With eyes on 2012, with the President seek to “triangulate” and find ways to make deals with Republicans on smaller provisions in health reform, or will he veto anything that alters the ACA?
  
  
• How would a defunding strategy work? The House Republicans may be thwarted by the Senate or the White House in affirmative proposals to pare back reform, but withholding money is much easier. Certainly, the myriad of authorized programs which lack funding would be less likely to get off the ground in a defunding environment, but what about the millions of dollars needed to simply implement required aspects of the law? If the law requires a Medicaid expansion and operational state health care exchanges in 2014 and HHS simply lacks the money to get those programs up and running, what happens then? Do consumers have a right to sue HHS? And if they win?

While there are clearly more questions than answers at this point, NAPH stands ready to defend the health care safety net and our hospitals’ patients against any threats coming from any direction next year.