WASHINGTON -- House Republicans unveiled their long-awaited legislation to repeal and replace the Patient Protection and Affordable Care Act, scrapping the mandate that nearly all Americans have health insurance and replacing it with a system of tax credits aimed at enticing Americans to purchase health care on the open market.
The House Energy and Commerce Committee and the House Ways and Means Committee, which drafted the bills, planned to begin voting on the 123-page legislation Wednesday, the next step in a seven-year Republican effort to repeal the 2010 law.
Republicans hope to undo key parts of President Barack Obama's signature domestic achievement, including income-based tax credits that help millions of Americans afford insurance, taxes on people with high incomes and the penalty for people who do not buy health coverage.
Under the Republican plan, the income-based tax credits would be replaced with credits that would rise with age. The age-based tax credits that may be skimpier for people with low incomes would phase out for higher-earning people.
The bill would continue Obama's expansion of Medicaid to additional low-earning Americans until 2020. After that, states adding Medicaid recipients would no longer receive the additional federal funds the statute has provided.
More significantly, Republicans would overhaul the federal-state Medicaid program, changing its open-ended federal financing to a limit based on enrollment and costs in each state.
Thirty-one states and the District of Columbia opted to expand Medicaid coverage under the law and accept beefed-up federal spending for the program, which has provided coverage to more than 10 million people. About half of those states have GOP governors who are largely reluctant to see that spending curtailed.
For the other 19 states that did not expand Medicaid, the legislation would provide $10 billion spread over five years. States could use that money to subsidize hospitals and other providers of care that treat many poor patients.
Some consumer protections in the Obama law would be retained, such as insurance safeguards for people with pre-existing medical problems and parents' ability to keep their children on their insurance until age 26.
House Speaker Paul Ryan, R-Wis., said the bill would "drive down costs, encourage competition, and give every American access to quality, affordable health insurance." He added, "This unified Republican government will deliver relief and peace of mind to the millions of Americans suffering under 'Obamacare.'"
Health Secretary Tom Price "welcomes action by the House to end this nightmare for the American people," spokesman Caitlin Oakley said.
The release of the legislation is a key step toward fulfilling a campaign pledge -- repeal and replace -- that has animated Republicans since the passing of the Affordable Care Act. But even after President Donald Trump's election in November, it is far from certain that Republican lawmakers will be able to get on the same page and repeal the health measure.
On Monday, four moderate Republican senators -- Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Lisa Murkowski of Alaska -- signed a letter saying a House draft that they had reviewed did not adequately protect people in states like theirs that have expanded Medicaid under the law.
Three conservative Republicans in the Senate -- Mike Lee of Utah, Rand Paul of Kentucky and Ted Cruz of Texas -- had expressed reservations about the House's approach. In combination, the conservatives and moderates have more than enough votes to block the bill in the Senate.
"It still looks like 'Obamacare'-lite to me," Paul said. "It's going to have to be better."
In the House, too, Republican leaders will have to contend with conservative members who have already been vocal about their misgivings about the legislation being drawn up. "Obamacare 2.0," Rep. Justin Amash, R-Mich., tweeted Monday.
The Republican tax credits -- ranging from $2,000 to $14,000 for families -- would be refundable, meaning even people with no tax liability would receive the payments. Conservatives have objected to that feature, saying it creates a new entitlement program the government cannot afford.
"Conservatives don't want new taxes, new entitlements and an 'ObamaCare Lite' bill," Rep. Mark Meadows, R-N.C., and Paul wrote on the website of Fox News. "If leadership insists on replacing ObamaCare with ObamaCare-lite, no repeal will pass."
Senate Finance Committee Chairman Orrin Hatch, R-Utah, wouldn't rule out changes in the measure by his chamber.
"The House has the right to come up with what it wants to and present it to the Senate by passing it. And we have a right to look it over and see if we like it or don't," Hatch told reporters.
Solid Democratic opposition is a given.
"Republicans have decided that affordable health care should be the privilege of the wealthy, not the right of every family in America," said House Minority Leader Nancy Pelosi, D-Calif.
Final work on the legislation was still underway over the weekend and Monday, according to individuals with knowledge of the process.
Lauren Aronson, a spokesman for the Ways and Means Committee, which is drafting the tax provisions of the bill, declined Monday to comment on specific provisions, saying the legislation was still being revised.
The tax credits outlined by the Ways and Means Committee's portion of the legislation incorporate an approach that Republicans have long criticized: income-based aid to help Americans afford health coverage.
Until now, the GOP had been intending to veer away from the health law subsidies that help poor and middle-class people obtain insurance, insisting that the size of tax credits with which they planned to replace the subsidies should be based entirely on people's ages and not their incomes. But the drafts issued Monday proposed refundable tax credits that would hinge on earnings as well as age -- providing bigger credits for older and poorer Americans.
The shift to take income into account in the age-based tax credits would drive away some Republicans, who regard a reduction in the federal government's role in health care as a central reason to abandon the 2010 law.
One motivation for the GOP thinking that credits should depend only on age was that the Internal Revenue Service would no longer need to verify the eligibility of people for financial help, as it has for Affordable Care Act subsidies. If income is taken into account, the IRS would still need to be involved.
The goal of lessening the government's role also is behind another key change from the 2010 law that the Republican plans envision: getting rid of the federal requirement that insurers include a minimum set of "essential benefits" in health plans sold to individuals and small businesses.
While Republicans have argued over how to proceed, Trump has expressed only vague goals for how to repeal the Affordable Care Act and improve the nation's health care system. On Capitol Hill, lawmakers and their aides were waiting to see whether he presses reluctant Republicans to get behind the House plan.
Information for this article was contributed by Thomas Kaplan and Robert Pear of The New York Times; by Alan Fram, Ricardo Alonso-Zaldivar, Mary Clare Jalonick and Andrew Taylor of The Associated Press; and by Amy Goldstein, Mike DeBonis and Kelsey Snell of The Washington Post.
A Section on 03/07/2017