That Republicans have failed to offer a single, comprehensive replacement bill for Obamacare has become a running joke in Washington over the last several years: They voted to repeal the law—in whole or in part—dozens of times, yet they’ve never kept their many pledges to replace it.
Contrary to the common criticism from Democrats, however, the GOP’s failure to back up its talk with action hasn’t stemmed from a lack of ideas. Republicans have plenty of ideas for how to overhaul the health-care system—they’ve just never been able to agree on enough of them to pass a plan through Congress.
On Wednesday, party leaders will try again, by unveiling a proposal that, for the first time, represents a consensus position of the House Republican conference over how the nation’s health-care laws should work if the GOP ever succeeds in repealing the Affordable Care Act. The long-awaited proposal doesn’t pick sides in the intra-party debate over health policy so much as it tries to piece together a hodgepodge of ideas that have circulated among conservative think tanks and campaign platforms for more than a decade, including those offered by John McCain in 2008, Mitt Romney in 2012, and several candidates who ran this year.
The GOP plan would:
- Expand health savings accounts
- Offer refundable tax credits to subsidize the purchase of private health insurance and decrease dependence on employer-sponsored plans
- Cap the tax exclusion for employer-provided health insurance
- Allow people to purchase insurance across state lines
- Provide $25 billion in funding for high-risk pools over 10 years
- Devolve Medicaid to the states, either through a block grant or a “per capita allotment”
- Partially privatize Medicare beginning in 2024 through a “premium support” option
Republicans are releasing the plan on Wednesday in a 37-page report written by a task force appointed earlier this year by Speaker Paul Ryan—the fifth in a six-part rollout of the party’s “A Better Way” agenda. And while the report may be the party’s most detailed official policy pronouncement on health care in many years, it is not a piece of legislation, and it will not come to a vote this year.
Indeed, the plan is more like an Impressionist painting: The closer you look, the fuzzier it appears. There’s no estimate for how much it would cost, how generous the tax credits would be, how many people it would cover, or how many people would be forced off of Medicaid or their Obamacare exchange policies. “It is a framework,” a House GOP leadership aide told reporters on a background conference call held to preview the plan on Tuesday. All of those questions, the aide said, would be “litigated” by the committees that actually translate the framework into legislation next year. “We would expect healthy job growth. We would expect premiums to drop,” the aide said, without being more specific.
One thing is clear, however: Republicans are recommitting themselves to the full repeal of Obamacare just a few weeks after a pair of GOP lawmakers, Representative Pete Sessions of Texas and Senator Bill Cassidy of Louisiana, released a proposal that scraps its mandates but maintains its underlying structure so that people who like their current plans can keep them. “Obamacare simply does not work,” the GOP report declares. “It cannot be amended or fixed through incremental changes.” The new proposal does envision “a transition period” to minimize disruption to the marketplace and allow people time to find new plans if states choose to do away with the exchanges created under the Affordable Care Act. But beyond a one-time open enrollment period, the specifics of how this would work are, again, hazy.
The plan would reinstitute some of the popular consumer protections in Obamacare, like a ban on insurance companies discriminating based on preexisting conditions, a cap on lifetime coverage, and allowing adult children to stay on their parents’ plans until age 26. But in a few cases, exceptions could apply. Republicans also wade into a less popular aspect of Obamacare by proposing to cap the kind of health insurance plans that can be excluded from income taxes. The concept is the same as the one that led Democrats to enact the so-called “Cadillac tax” on expensive policies in the Affordable Care Act—a levy that they agreed to repeal at end of last year. But while a cap on exclusions targets the same high-cost insurance plans, Republicans argue that it’s a “fundamental departure” from the Cadillac tax that would better account for low-income workers and areas that have a higher cost of living.
If there’s a surprise in the plan, it’s that Republicans included elements of Ryan’s controversial proposals to overhaul Medicare and Medicaid, which were not mentioned when the speaker outlined his agenda at the beginning of the year. The House leadership aide said that over the last few months, a consensus emerged among lawmakers that they could not propose to fix the health-care system without touching the main drivers of federal spending and debt—entitlement programs. The inclusion of those reforms will probably cheer conservatives who have called on Republicans to be more aggressive, but they may set up a clash with Donald Trump, who has campaigned against Ryan’s ideas in the past.
That is nothing new. Most of, if not all, of the House GOP’s agenda presents a contrast with Trump—both in its substantive details and in the existence of substantive policy at all. But as with the other proposals, Republicans are waiting for Trump’s election to do the truly hard work of filling in the details, rounding up the votes, and trying to pass their health-care plan into law. Without a President Trump, that long-awaited Obamacare replacement bill gets another few years to sit on the shelf.