The GOP's takeover of Congress could mean more battles with the President and Democrats, or could lead to the changes Americans want.
New Senate Majority Leader Mitch McConnell and House Speaker John Boehner must decide whether pushing for changes to Obamacare is a wise political investment.
The historic takeover of the Senate gives Republicans a powerful opportunity to reshape a health care landscape that's been almost singularly defined these last six years by President Obama and his Affordable Care Act.
Figuring out how to exercise that authority to improve the law's flaws without overreaching and returning the federal government to total gridlock is a complicated task.
But from the start, let's be clear: The GOP can claim a mandate to reform what remains, a year after its error-riddled rollout, a deeply unpopular law.
One of the biggest reasons Republicans took back control of the Senate was broad voter dissatisfaction with the Affordable Care Act. On the campaign trail, candidates hammered the point home relentlessly.
In exit polls, 48% of voters said the President's signature health care law went too far; just 21% said it was about right.
This does not mean that the GOP can easily repeal the law. The filibuster in the Senate, combined with Obama's veto pen, give the Democrats serious leverage. Obama also said this week that removing the law's individual mandate "is a line I can't cross" because it would undermine the statute's basic framework.
But both the House and Senate can and should act decisively to fix some of Obamacare's most harmful side effects. And there are all kinds of things that President Obama wants — from government spending to reauthorizing legislation to confirming his nominees — which he will only be able to get upon giving some concessions back to the Republicans.
Some might characterize this as hostage-taking, but it really just basic democratic deal-making. It is important to remember that the biggest bipartisan deals in the Clinton administration, such as welfare reform and the budget compromise, came in the period when Republicans controlled both the House and Senate.
And what's poorly understood is that many of the most pressing Obamacare fixes can and should win substantial Democratic support, so they should not set off major partisan wars.
At the top of this list for reform is the medical device tax, which incoming Majority Leader Mitch McConnell correctly calls "deeply, deeply unpopular with the American people."
Device tax critics see this 2.3% tax on medical devices as a tax on innovation — and with the backing of Democratic Senators like Amy Klobuchar and Al Franken, from medical device hub Minnesota — this initiative could make it onto Obama's desk with bipartisan backing.
A second point of attack is the bill's definition of the work week. The ACA's definition of 30 hours as full-time employment provides perverse incentives to employers to reduce the number of hours worked so as to avoid the ACA's requirement that employers provide health insurance or pay a penalty.
Raising the limit to 40 hours a week would end this incentive to reduce the numbers of hours worked. Given the potentially positive impact on employment, changing the definition in this way should generate support from both sides of the aisle.
Third is the excise tax, which both business and labor have concerns with. The threshold for paying this tax, designed to hit high value, "Cadillac"-style health plans, increases over time, and not according to medical inflation.
As a result, an increasing number of plans will trigger the excise tax over the next two decades; by 2031, the average family health care plan is expected to hit the excise tax threshold. The impact that the excise tax will have on lower-income workers, as well as opposition to the tax from both labor and business, could help generate bipartisan support for getting an excise tax repeal through Congress and to President Obama.
The crucial question McConnell and House Speaker John Boehner must reckon with is whether pushing hard for changes to Obamacare is a wise political investment.
Some in the GOP believe that changing the law without repealing it is a strategic error. Under this theory, an improved law might become more popular, and therefore harder to repeal should the GOP gain control of both Congress and the presidency after a future election.
On the other side of the equation is Congress' understandable desire to prove to the American people that Washington can get things done.
Getting rid of the device tax will help device manufacturers.
Changing the definition of full-time work could strengthen the job market.
Repairing the excise tax will reduce the pressure on employers to engage in cost sharing to reduce the value of their health plans and hence their exposure to the tax.
Far better to fix those problems now when the opportunity is at hand. As President Obama just learned, future elections do not always bring you what you want.