Incoming Republicans are speaking of using the reconciliation process twice next year with the first one used to repeal the Affordable Care Act. Some speculate that could take place as early as late January.  The mantra for opponents of the ACA for over six years has been “repeal and replace’ but the replace part is a challenge. Repeal of the ACA is projected to increase the deficit by approximately $350 billion over ten years and it would leave more than 20 million Americans without health insurance.

To simply repeal the ACA would cut people off some with serious health access issues.  In addition, President-elect Trump has indicated he would want to continue some of the more popular provisions especially the requirement that insurance companies not deny insurance to people with previous health conditions (e.g. heart disease, diabetes, cancer histories, etc.). The challenge is that the ACA makes covering all pre-existing conditions possible by mandating everyone have health insurance (individual mandate) which has the effect of increasing the insurance pool.  Simply requiring companies to provide insurance to all comers could be accomplished but insurance companies would charge prohibitively costly premiums.  The ACA also provides tax credits that reduce premiums for millions of current enrollees.

Some Republicans have discussed they could repeal the ACA early with perhaps a two-year implementation while they decide what the replacement should be. If they pursue this strategy, then they would likely attempt a repeal in January as a symbolic victory.

The second reconciliation would be a tool to address other priorities. Speaker Ryan has proposed and written past budget resolutions that would convert Medicaid into a block grant along with the SNAP program.  Both are part of an anti-poverty agenda that in theory would give states more flexibility in spending health care and nutrition funding.  Such a reconciliation could also include changes to Medicare, the tax cuts Republican leaders have been seeking and an infrastructure package that the President elect and many Democrats want.  One of the reconciliations could also change the current budget caps which restrict spending increases and hold domestic spending and defense spending in a rough parity.  That is, increases in defense have been contingent on also providing increases on the domestic side.

In between the two reconciliations would be an appropriations bill that would finish up funding for the current fiscal year.  That bill could allow cuts to other programs and priorities.