Mitt Romney stirred up a hornets' nest earlier this month when he made comments on "Meet the Press" that some interpreted as his going wobbly on his promise to fully repeal Obamacare.
"I'm not getting rid of all of health care reform," Romney said. "Of course, there are a number of things that I like in health care reform that I'm going to put in place."
His campaign later clarified, in a statement to National Review, that when Romney said he would "make sure that those with pre-existing conditions can get coverage," Romney meant he would "ensure that discrimination against individuals with pre-existing conditions who maintain continuous coverage is prohibited." This didn't stop the flood of commentary over what Romney's true intentions would be if he won the presidency.
For all the debate over his remarks, though, the reality is that the policy Romney pursues on health care will be largely dictated by the postelection composition of the U.S. Senate.
Should Democrats retain control, there will be little hope of repealing Obamacare. The best Romney would be able to do would be to make small tweaks around the edges and delay the implementation of the parts of the law over which the executive branch was given regulatory discretion.
If Republicans gain control of the chamber and maintain their majority in the House of Representatives, health care policy will be influenced by the strength of the conservative caucus.
A perilous 50-50 Senate GOP majority with a Vice President Paul Ryan as the tie-breaking vote would make full repeal of Obamacare difficult, even if Romney is dedicated to it. Just one moderate Republican (such as a re-elected Sen. Scott Brown of Massachusetts or Sen. Susan Collins of Maine) could halt the move. The same could prove true even if Republicans had a stronger majority, but one that wasn't comprised of enough principled conservatives.
If groups such as FreedomWorks and Sen. Jim DeMint's Senate Conservatives Fund succeed in getting enough limited-government Republicans elected to the chamber, and that free market contingent becomes a majority within a GOP majority, then it's more likely that Romney will be forced to pursue full repeal, even if he would like to keep some parts of the law.
Even if limited-government Republicans achieve critical mass in the Senate, however, it's still no guarantee that such an attempt to fully repeal Obamacare will succeed. That's because Republicans won't have 60 votes needed to break Democrats' filibuster. They'll have to approach repeal through the budget reconciliation process, which allows for the passage of budget-related legislation with a simple majority, but is subject to restrictions.
There is much debate about how much could be repealed in this way. Most people agree that the major spending provisions -- such as the Medicaid expansion and subsidies for people to purchase health insurance on government exchanges -- could be repealed because of their deficit-reducing impact. It's less clear whether the tax increases, Medicare cuts and regulations could be thus undone.
Many conservatives are under the impression that the entire health care law was passed through reconciliation in the first place, which leads them to believe it can be easily repealed that way. That simply isn't so. The Democratic House passed the version of Obamacare that had already cleared the Senate with 60 votes. Democrats only used reconciliation to pass a package of changes to the Senate bill as part of an agreement between the two chambers and the White House.
No doubt, if Romney is elected, presidential leadership will play a critical role in shaping the future of the nation's health care system. But much of the policy will be driven by the outcome of this year's Senate elections.
Philip Klein (firstname.lastname@example.org) is a senior editorial writer for The Washington Examiner. Follow him on Twitter at @philipaklein.