The 115th Congress started work Tuesday with Republican majorities in both the House and Senate in agreement on their top priority -- to repeal and replace the 2010 health law, the Affordable Care Act.
"The Obamacare experience has proven it's a failure," House Majority Leader Kevin McCarthy, R-Calif., told reporters at an opening day news conference.
But that may be where the agreement among Republicans ends. Nearly seven years after its passage, Republicans still have no consensus on how to repeal and replace the measure.
"It is risky business," said Thomas Miller, a conservative economist and former Capitol Hill aide now at the American Enterprise Institute.
Republicans, he said at a recent AEI forum, are "very good at fire, aim, ready." But with more than 20 million Americans getting coverage under the law, GOP lawmakers will have to tread carefully, Miller warned. "The hard one is when you're trying to defuse what's already been out there, cutting the wires on the bombs sequentially" so as to avoid a messy and destructive explosion.
Republicans are reportedly discussing a range of options for disassembling Obamacare, but analysts who have been involved in the intricacies of health policy for decades warn no replacement strategy will be easy.
The most immediate problem for the GOP is that even with majorities in both chambers of Congress, they do not have the 60 votes needed to overcome Democrats' objections in the Senate. (There are 52 Republicans in the Senate now.) That means they won't be able to pass a full repeal of the law on their own, and it is unlikely eight Democrats would join to overturn President Barack Obama's signature legislation.
Even if they did have the votes standing by, they don't have anything teed up to replace the health law.
"It's not that Republicans don't have replace bills. They have a couple dozen," said Douglas Badger, who oversaw health policy in the White House for President George W. Bush and worked for the Senate GOP leadership prior to that. "The problem is they don't have consensus," he said at the AEI forum.
Still, doing nothing, or even waiting, is not an option given that these lawmakers have been vowing to repeal the law almost since the day it passed in 2010.
"You have to pass something," said Miller, "and whatever you pass you call repeal."
The leading option under consideration is "repeal and delay." The idea is to use the budget process to overturn the tax-and-spending parts of the law, but delaying the effective date to buy time for Republicans to agree on a replacement bill.
But there are problems with that strategy. One is political -- Democrats are already crying foul.
"It's not acceptable to repeal the law, throw our health care system into chaos and then leave the hard work for another day," incoming Senate Minority Leader Charles Schumer, D-N.Y., said Tuesday.
Added Sen. Richard Durbin, D-Ill., "it's not repeal and delay, it's repeal and retreat."
The plan also has raised concerns in the health industry. The goal of delaying the repeal date is to let people who have obtained insurance under the health law keep it while a replacement is formulated. But that is by no means guaranteed.
Insurance analysts have said that any more uncertainty in an already fragile marketplace could easily prompt insurers to leave the individual market, which would put at risk coverage for not just the roughly 10 million people who are purchasing plans there under the health law, but also the roughly 10 million people who previously had individual policies. (Another 10 million people have gained coverage under the health law through an expanded Medicaid program for those with low incomes.)
Without specific help for insurers from Congress, which would likely include insurance payments Republicans have called bailouts, "the market will begin to crumble" quickly, said Robert Reischauer, former president of the Urban Institute.
House Majority Leader McCarthy told reporters Tuesday that "no decisions have been made yet" on how Republicans might want to help stabilize the insurance market while they seek a replacement plan.
The individual insurance market could also be rattled if the incoming Trump administration decides not to appeal a lawsuit brought by congressional Republicans who argued that the Obama administration was illegally using money to pay insurers to subsidize health costs for some low-income customers buying individual plans on the health law's marketplaces. If the new administration bows out of the suit and those subsidies, insurers would not get reimbursed for the expenses, and some analysts predict it could force companies to leave the market.
On the other hand, attempting to repeal and replace the law in a single bill also could pose problems.
Repealing and replacing together "looks less like repealing than fixing," said Badger. "That could cause some angst" among the GOP base that wants Obamacare to be fully eliminated.
And Democrats point out that Republicans are equally guilty of overpromising the benefits of overhauling the health care system, albeit in a very different way.
The goals currently being talked about by Republicans -- including making health care more affordable, covering more people, reducing government spending and giving states more flexibility -- "are impossible to achieve," within acceptable GOP budget limits, said Reischauer at the AEI event. "There are going to have to be some tradeoffs," he said, as Democrats found when they tried to accomplish roughly those same goals.
