As we look ahead to the 115th Congress, Republicans are likely to take up repeal and replacement of the Affordable Care Act. Repeal and replace is more accurately described as a transition where Republicans design a version of health care reform they will own and defend. In doing so, Republicans must consider three important factors as they look at policy. The first two, talking with insurers and avoiding coverage disruption, were discussed in our prior blogs. The third is making hard choices.

The economist Thomas Sowell is often credited with this quote “There are no solutions, only tradeoffs.” In 2009, the Democrats made tradeoffs in constructing the Affordable Care Act. Now it will be the Republicans’ turn to make tradeoffs as they move to transition away from the Affordable Care Act. Republicans will consult stakeholders and experts and will engage the Congressional Budget Office, especially around coverage and costs. Republicans will then have to make hard choices based on the information they receive.

One specific example will involve Medicaid. Will Republicans reduce the special matching rate states receive to cover those who are newly eligible under the Affordable Care Act? They are certain to be told that drastically reducing the matching rate will cost millions of Americans their Medicaid coverage. States have made the decision to cover these low-income individuals, but if the payment is reduced, it is highly likely that state budgetary pressures will force many states to make the difficult decision of reducing or eliminating coverage.

Republicans are going to receive information about the coverage and cost consequence of their policy choices. They are going to be told things they may not have expected or wanted to hear. They will then have to decide if they want to reconsider or proceed and face the consequences.

In the end, Republicans are about to be able to engage in health care policy making in a way they weren’t in 2009. Republicans want to show they have a better way (the title of the House Republican platform). Their policies will produce coverage and cost numbers. They must decide then how they will proceed. Decisions will have consequences, and they will own those consequences.

In the coming days, we’ll be continuing to cover health care reform in the 115th Congress with a focus on specific health care programs. Stay tuned!