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Trump's Obamacare Quandary

Elected on a promise to dismantle the Affordable Care Act (also known as Obamacare), President-elect Donald Trump is now well-positioned to put a spike in its heart. With Republicans controlling both Houses of Congress, a bill to repeal the health care law could be passed and signed next month. But now there's a problem: It turns out most Americans actually like most parts of the law, raising political risks for those who repeal it without providing a suitable alternative.

The Kaiser Family Foundation released a major new poll yesterday, probing American's views of the controversial legislation. Barely one-fourth of Americans (26 percent) want to see the law dismantled, and 17 percent want to see it trimmed; but 30 percent want it expanded, and 19 percent want it to go forward as is. Moreover, voter attitudes toward Obamacare are become more favorable as they contemplate the reality of life without it. In October, before the election, 69 percent of Republicans wanted to repeal the entire law. Just a month later, only 52 percent wanted to repeal.

Unfortunately for politicos who want a total repeal, some provisions of the health care law are extremely popular with members of both political parties. The provision that allows young adults to stay on parents' policies until age 26 is a huge winner, with 90 percent of Democrats and 82 percent of Republicans wanting to keep it. Eliminating out-of-pocket cost for routine preventive services is also popular, favored by 77 percent of republicans and 89 percent of Democrats.

The brunt of repealing Obamacare will fall disproportionately on Trump voters, even though most don't realize it yet. On average, Trump voters are older and hence they face greater health care costs. They live disproportionately in states with higher obesity rates, and this too leads to higher costs. And they work disproportionately in low- and middle-income service jobs (now that high-wage unionized manufacturing is all but gone). As a result they have less access to the generous employer-sponsored plans that prevail in the tech sector. Increasingly they are contractors with no employer-provided coverage at all.

Trump apparently recognizes the political risk, and he's backpedaling furiously. Recently on television he pledged to keep the protections for people with preexisting conditions. And he said he'd keep the provision that allows young adults to stay on their parents' plans. But apparently the Donald Trump that made that speech is not talking to the Donald Trump who is choosing Cabinet heads. Tom Price, the nominee for Health and Human Services, has long championed not only the repeal of Obamacare, but the dismantling of Medicare as we know it.

Will the real Donald Trump please stand up?

Meanwhile there's a fight between Republicans in Congress over how to approach repeal (or amend). The realists understand the political risk of scrapping the popular provisions; they want to keep the current system in place until something better can be devised. The idealists like Price and House Speaker Paul Ryan want to trim all government involvement in health care (Medicare, Medicaid and the Veterans Administration), and they want to seize this opportunity now, regardless of potential blowback from voters. A compromise is emerging to kick the can down the road. The Affordable Care Act would be formally repealed now, but the repeal wouldn't take effect for two to three years. This would give Congress some time to devise an alternative. It opens a myriad of possibilities for political leverage if the replacement bill comes up for a vote right around the time of the 2018 congressional elections.

It's very hard to tell what is going to happen to the law, and to the 16 million Americans who only have coverage because it exists. But one thing is clear: The dog has caught the firetruck. Letting go is dangerous, but so is hanging on.

David Brodwin is a co-founder and board member of American Sustainable Business Council. This blog is adapted from a column recently published in U.S. News & World Report December 2, 2016.