GOP on ACA replacement: Who wants what?

Republicans in Congress have already laid the foundation for an ACA repeal through the reconciliation process, but what will replace the law still remains uncertain. 

And while Republicans agree the ACA needs to go, they have not coalesced around a single plan yet. To provide some clarity around the replacement ideas out there right now, we pulled highlights from statements and plans put forth by President Donald Trump and several Republican leaders. 

1. President Trump. A week ahead of Inauguration Day, President Trump told The Washington Post he was nearly finished crafting a replacement for the ACA and is waiting to unveil it until his nomination for secretary of HHS, Rep. Tom Price, MD, R-Ga., is confirmed. 

"We're going to have insurance for everybody," President Trump said, according to The Washington Post. "There was a philosophy in some circles that if you can't pay for it, you don't get it. That's not going to happen with us." President Trump's plan will be simple and less expensive than the ACA, he added, by increasing competition in the insurance marketplaces.  

Throughout his campaign, President Trump supported the sale of insurance across state lines, a move intended to drive competition and give consumers more choices. He has also been a proponent of moving Medicaid to block grants; creating individual, tax-free health savings accounts; and allowing pharmaceutical companies and Medicare to directly negotiate prices with each other in an effort to drive down drug costs. 

2. Rep. Tom Price, MD, R-Ga. Rep. Price, who awaits a final hearing Tuesday in the Senate finance committee on his nomination for secretary of HHS, previously put forth a health plan called the "Empowering Patients First Act." Much of this plan aligns with President Trump's views, such as establishing individual HSAs that can be rolled over to family members or allowing interstate insurance sales. 

One hallmark of Rep. Price's plan is the creation of "association health plans," which Sen. Rand Paul, R-Ky., highlighted during Rep. Price's hearing in the Senate health committee this week. These health plans allow small business owners to group together through a trade or professional association to purchase coverage. During the hearing, Rep. Price called association health plans "one of the secrets to being able to solve the market conundrum we find ourselves in." The plan is similar to an offering through Blue Cross Blue Shield a few decades ago, he noted. "It just makes a lot of sense. It allows insurance to work the way its supposed to work, which is to spread the risk," Rep. Price said.  

However, Rep. Price's views do differ slightly from President Trump. One difference that has gotten particular attention this week is his opinion on direct negotiation between Medicare and the pharmaceutical industry.

Grilled by Sen. Bernie Sanders, I-Vt., on whether or not he would support such policies during his Senate hearing this week, Rep. Price did not provide a direct answer. "You have my commitment to work with you and others to make certain that the drug pricing is reasonable and that individuals across this land have access to the medications that they need," Rep. Price said. 

During the hearing, his plan was criticized by Sen. Patty Murray, D-Wash., for potentially eliminating some of the safeguards around those with pre-existing conditions and for people under age 26. Rep. Price said insurance companies plan to include stipulations to allow children to stay on their health plans until age 26 going forward, "So we felt it was covered." He also disagreed with Sen. Murray's suggestion that people with pre-existing conditions would not be able to secure coverage under his plan.

"We would put in place high risk pools and individual health pools that would allow every single person in the individual small group market, who are the ones challenged with pre-existing illness, to be able to gain access," Rep. Price said.   

3. House Speaker Paul Ryan, R-Wis. Speaker Ryan and Rep. Price's plans overlap significantly. Speaker Ryan's most recent plan, entitled "A Better Way," was released in June and touted as the mainGOP agenda at the time. The plan includes refundable tax credits, similar to the ACA subsidies, that are adjusted to grow with age. It also includes provisions for the sale of insurance across state lines, calls for allowing small businesses and individuals to pool together for health coverage and protects pre-existing conditions and dependents up to age 26. Perhaps most notably, the plan aims to establish private alternatives to Medicare by 2024 to "save and strengthen the program," according to an overview of the plan. 

"Medicare works; the problem is it's going bankrupt … in the next decade," Speaker Ryan said during an interview Wednesday with Charlie Rose of PBS. However, not all Republicans are onboard to start tinkering with Medicare. In December, several Republican leaders in Congress suggested changing Medicare and the ACA would be too much at once, and "would fall in the category of biting off more than we can chew," said Sen. Lamar Alexander, R-Tenn., according to Politico.  

4. Sen. Bill Cassidy, MD, R-La. Sen. Cassidy, a physician from Louisiana, is behind "The World's Greatest Health Care Plan," which was introduced last year with Rep. Pete Sessions, R-Texas. Though the bill was titled to get media attention, Sen. Cassidy told NBC this week, the plan would be a cheaper alternative to the ACA, he said. "We spoke to an insurance group recently and they said our model — everyone enrolled unless they chose not to be — could, in and of itself, lower premiums by 20 percent, because you now have the law of big numbers," Sen. Cassidy told NBC. "It's not just the sick and old signing up ... you get everyone in. So that's a 20 percent reduction right there, but you've done it by expanding coverage."

The plan would make the ACA optional by offering health tax credits for those without employer-based coverage or coverage from the exchanges. It would send "unclaimed tax credits" for the uninsured to safety net hospitals. The plan also does away with coverage mandates, puts states in charge of Medicaid funding and establishes HSAs. 

5. Sen. Rand Paul, MD, R-Ky. Sen. Paul has been working on legislation to replace the ACA, according to a Bloomberg report. The legislation sounds fairly similar to most of the Republican plans out there — tax credits, health savings accounts and association health plans. Where Sen. Paul has stood apart from other Republicans is his steadfast commitment to not repealing the ACA without a replacement ready. In early January, he tweeted, "I just spoke to @realDonaldTrump and he fully supports my plan to replace Obamacare the same day we repeal it. The time to act is now."

He was notably the only Republican to vote against the budget resolution in the Senate earlier this month — not because it paved the way for the ACA repeal — but because the budget added nearly $10 trillion to the debt. "As a physician, I cannot wait to repeal Obamacare and replace it with a healthcare system that relies on freedom to provide quality, comprehensive, and affordable care," Sen. Paul said, according to the Lexington Herald Leader. "But putting nearly $10 trillion more in debt on the American people's backs through a budget that never balances is not the way to get there. It is the exact opposite of the change Republicans promised, and I cannot support it, even as a placeholder."


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