No GOP consensus yet on replacing health act

Phased-in repeal foreseen by aides on Hill

WASHINGTON -- The first major act of the unified Republican government in 2017 will be a vote in Congress to begin tearing down the Patient Protection and Affordable Care Act.

But despite their eagerness to repeal President Barack Obama's signature health care law, Republicans -- and President-elect Donald Trump -- have no agreement thus far on how to replace coverage for about 20 million people who gained insurance under it.

"They haven't come to a consensus in the House and the Senate about the possible replacement plans," said Douglas Holtz-Eakin, a conservative economist and former adviser to Sen. John McCain's 2008 presidential campaign. "They don't know Point B."

Some Republicans are debating how long to delay implementing the repeal. Aides involved in the deliberations said some parts of the law may be ended quickly, such as its regulations affecting insurer health plans and businesses. Other pieces may be maintained for up to three or four years, such as insurance subsidies and the Medicaid expansion. Some parts of the law may never be repealed, such as the provision letting people under age 26 remain on a parent's plan.

House conservatives want a two-year fuse for the repeal. Republican leaders prefer at least three years, and there has been discussion of putting it off until after the 2020 elections, staff members said.

In the nearly seven years since the law passed, dozens of comprehensive health care alternatives have been introduced, but none has gotten off the ground. The most developed plan so far is legislation by House Budget Committee Chairman Tom Price of Georgia, Trump's nominee to run the Department of Health and Human Services, which he has introduced in every Congress since 2009. It had 84 co-sponsors in the House.

But that bill -- centered on age-based refundable tax credits to buy insurance -- didn't receive a hearing in committee, nor was it included in Price's budget that was adopted by the House last year.

If Republicans stick together, repeal could happen quickly. The Senate plans to move first on a nonbinding budget resolution instructing committees to draft repeal legislation, with the House approving it next. The resulting proposals would be sent for final votes under a process known as reconciliation, which is used to bypass the 60-vote threshold in the Senate.

Key Republicans responsible for executing the plan will be Senate Finance Committee Chairman Orrin Hatch of Utah and Health Committee Chairman Lamar Alexander of Tennessee, and on the House side, Ways and Means Committee Chairman Kevin Brady of Texas and incoming Energy and Commerce Committee Chairman Greg Walden of Oregon.

GOP leaders are portraying the Affordable Care Act as collapsing on its own. But the Department of Health and Human Services reported that sign-ups reached 6.4 million by the Dec. 19 deadline, an increase of 400,000 over the previous year's number at this time. Earlier, Obama said more than 670,000 Americans signed up for coverage on Dec. 15, "the biggest day ever for healthcare.gov."

"The overarching challenge is that the Affordable Care Act is the status quo, and disrupting the status quo in health care is always controversial," said Larry Levitt, a health policy expert at the Kaiser Family Foundation and former adviser to President Bill Clinton's health care efforts. "There are so many moving pieces to this effort involving lots of money and lots of interest groups. So piecing together the votes is daunting."

Trump and House Speaker Paul Ryan of Wisconsin have released blueprints calling for expanding the use of tax-advantaged Health Savings Accounts, allowing the sale of insurance across state lines and turning Medicaid over to states.

Unifying the party may require trial and error, said Rodney Whitlock, a former health policy aide to Republican Sen. Charles Grassley of Iowa, adding that Ryan will be a key figure to watch. He may have to get the Congressional Budget Office to provide estimates for how multiple proposals would affect the budget deficit, Whitlock said.

The Congressional Budget Office has said repealing the law would increase the number of uninsured by 24 million and increase the deficit by $353 billion over a decade, or $137 billion under favorable macroeconomic assumptions. Republicans argue that their plans will reduce the deficit and continue people's coverage.

"The new big lie, after 'if you like your health care plan you can keep it,' is that 20 million Americans will lose their health care. That's simply not true," Brady told reporters Dec. 15. "Republicans will provide an adequate transition period to give people peace of mind that they will have those options available to them as we work through the solutions."

A Section on 12/30/2016

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