The House GOP emerged from its retreat earlier this month united in its goal to come up with an alternative to Obamacare. But the deeper into health policy the members dig, the more difficult finding consensus will become.
Republicans have determined that they will select pieces of different GOP proposals rather than simply put forth one of the party’s old plans as its main health proposal. The older conservative health plans are unworkable in a post-ACA world.
The GOP retreat also produced consensus on several policy areas, but crucial questions must be answered later. For better or worse, Obamacare has now been the law of the land for six years and has drastically changed the entire health care system. It has resulted in more than 17 million people obtaining health care coverage and a brand-new insurance marketplace in every state. Any workable replacement plan must account for these major changes and describe how it will transition away from the ACA system.
That also means a replacement plan might have to answer some politically unpopular questions such as whether it is OK for some people to lose government-created health insurance or how much taxpayers should foot the bill, if at all, for poor people to have health care. These are sophisticated ideological questions that require more than a cursory knowledge of health policy and a willingness to dig deep into all the options and get creative. House Speaker Paul Ryan (R-Wis.) relishes that task, but bringing the GOP caucus along with his thinking is its own challenge.
“I know Ryan would like to be very bold, but he sometimes gets a little too far in front of his caucus. He is able and willing to engage in complex discussions on health care, but the rest of the GOP caucus is not so well-versed,” said one Republican lobbyist.
The goal that emerged from the GOP retreat is for the party to rally around a new plan that incorporates elements of proposals that are already out there, according to a senior GOP aide. That includes those put forth by House Budget Committee Chairman Tom Price (R-Ga.), the Republican Study Committee, and Energy and Commerce Committee Chairman Fred Upton (R-Mich.), who has been joined by Senate health wonks Sens. Orrin Hatch and Richard Burr in sponsoring a multi-faceted ACA replacement bill.
Here are areas of consensus, according to the GOP aide: There should be “some kind of tax subsidy” for people who don’t get insurance through their employers. It could be a refundable tax credit or a deduction. Insurers also should be able to sell across state lines, and there shouldn’t be mandates about what insurers must cover. Republicans also want to get rid of the individual mandate and create “expanded incentives” to use health savings accounts.
But those are somewhat easy things to agree on. Somewhere down the line, if Republicans go the route of creating a full-fledged plan, comes the tougher conversations: What do they do about Medicaid expansion? How generous should tax credits be? How do they make insurance affordable while increasing the quality of care? (Both of those things, they say, Obamacare has failed to do.) How do they achieve long-term budget savings, or at least avoid adding to the deficit? And how do they transition to a new health care system smoothly, without stripping people of their insurance?
Leadership is in agreement that whatever plan emerges, it must include a transition from Obamacare. But the full caucus isn’t ready for that level of detail yet, the aide said. Not many members know health policy as well as Ryan does.
Rank-and-file Republicans are, however, well-versed in anti-Obamacare rhetoric. “Repeal and replace” is a mantra every Republican can unite behind. Even here, though, there is a difference between those who say they want to repeal every last word of the law and (generally wonkier) lawmakers who are more open to a pick-and-choose approach. Only a handful will admit that the latter should even be an option.
Sen. Chuck Grassley (R-Iowa), who was ranking member of the Finance Committee when the health care law passed, is a pragmatist. He believes that the end result is the same whether the ACA is replaced entirely or undergoes major reconstructive surgery.
“You repeal and bring a whole new bill in after you repeal, or whether you take the Affordable Care Act and strike some things out, leave them out, or strike some things out and replace them with other things, you’re going to end up with the same product,” Grassley told Morning Consult in a recent interview.
“I tell my constituents that people tell me, even just last week, that out of this 2,700 page bill (I never know how many pages to include) there’s some of it that I wrote. Relatively noncontroversial, because we’ve been working on it for years, and it was just a vehicle to put them in. And those things will probably be left there,” he said.
That said, he didn’t attend the GOP retreat, and it’s unclear how many of his colleagues share this opinion, or at least will speak about it as candidly.
Grassley said it’s a good idea for Republicans to put out an alternative, but actually voting on it while President Obama is in office might not be necessary.
Putting forth a specific bill is dangerous in its own right. Vague plans can’t be scrutinized or evaluated by number-crunchers like the Congressional Budget Office. Creating a money-saving health overhaul bill is easier to talk about than to actually create, especially if it maintains coverage for the millions who have gained it under Obamacare and also eliminates mandates. Any plan that raises the deficit is also sure to draw the criticism of deficit hawks. A plan that results in people losing insurance, especially low-income people, will be heavily criticized by Democrats and patient advocacy groups.
These questions mean little to the Republican voter base. They don’t want to be told Obamacare will be amended or modified. They want it gone.
That’s why many Republicans continue to rely on tried and true talking points without delving into the details. “Number one is repeal the health care law and replace it with patient-centered care,” said Sen. John Barrasso (R-Wyo.), one of Obamacare’s most vocal opponents. “And so we will repeal the law that’s written.”