By Joe Infantino, senior staff writer
As it stands, the mechanism Republicans will use to repeal the Affordable Care Act (ACA) seems clear: budget reconciliation. Their plan to replace the law, however, is less so.
ACA opponents, including lawmakers and conservative think tanks, have offered a slew of replacement plans—at least eight, with significant variation in details:
Here's a look at the proposals and how they align and differ on certain hot-button topics:
Republicans haven't agreed on a single plan yet. But among the list of options, two stand out as the likely foundation for potential health care reforms under the Trump administration: those offered by Price and Ryan.
'A Better Way'
Ryan's A Better Way for health care, released in June, builds upon the health reform plans released by Burr, Hatch, and Upton, and Price. The plan would repeal the ACA in its entirety, including its coverage mandates, exchanges, subsidies, and taxes.
In its place, A Better Way would implement a series of sweeping reforms to the individual market and Medicaid that, ultimately, would increase the number of uninsured U.S. residents by four million, compared with current numbers, according to estimates from the Center for Health and Economy.
The individual market
Under Ryan's plan, consumers would receive age-based tax credits to help offset the cost of premiums, with the largest credits going to older people.
The credits would be made available at the beginning of every month. Any amount left over could be invested in an expense account similar to a Health Savings Account, a mechanism that Republicans tout as a way to support cost-sharing.
The plan also calls for $25 billion to be invested over 10 years in high-risk pools, which subsidize coverage for people with pre-existing conditions. In addition, the plan would impose a so-called "continuous coverage" requirement. Under that policy, insurers could not charge sick people more for coverage as long as beneficiaries maintain continuous coverage. But those who go without coverage for a given length of time could face higher costs when they search for a health plan.
The A Better Way proposal also would:
- Allow insurers to charge older consumers up to six times more for premiums than younger policyholders;
- Allow young adults to stay on their parents' health plans until age 26; and
- Make it easier for insurers to sell health plans across state lines.
A Better Way would overhaul the Medicaid program and transition it to a block grant program, which Republicans say would give states more flexibility to determine benefit offerings. States that expanded their Medicaid programs under the ACA would be allowed to keep those expansions.
Experts estimate that a block grant program would cut Medicaid funding over time. For example, the Bipartisan Policy Center estimated that Ryan's block grant program proposed in the fiscal year 2015 budget plan would cut Medicaid funding by 26 percent by 2024.
The A Better Way plan also would allow states to:
- "Charge reasonable enforceable premiums" for coverage; and
- Enforce work requirements.
Empowering Patients First Act
With Price poised to serve as the next HHS secretary, Republicans' likely steps to replace the ACA may have grown a little clearer, as he will be significantly involved in those discussions if his appointment is confirmed.
A long-time opponent of the ACA, Price has proposed replacement legislation (currently HR 2300) every year since 2009. The Empowering Patients First Act in its current form would repeal the ACA in its entirety and replace it with certain popular conservative policies.
The individual market
Price's plan would provide consumers with age-based tax credits to purchase coverage, maxing out at $3,000 for those ages 55 and older—who are more likely than younger patients to be sick.
While the ACA completely bans insurers from charging more for individuals with a pre-existing condition, Price's bill gives insurers some wiggle room. Under the bill, consumers who have continuous coverage—which the bill deems as having had insurance for at least 18 months—are safe from additional charges for their condition. However, those who have been uninsured could face higher premiums for up to 18 months under their new plan.
In addition, the plan calls for $3 billion to subsidize high-risk pools—significantly less than Ryan's proposal. The legislation also promotes the:
- Sale of health plans across state lines; and
- Use of Health Savings Accounts.
Price also has proposed significant changes to Medicaid, and like Ryan he has called for:
- Turning Medicaid into a block grant program, with the aim of giving states more control and flexibility over the program;
- Enforcing work requirements for "able-bodied" beneficiaries to receive benefits.
Price's plan also includes an opt-out provision, under which individuals could forgo Medicaid—as well as Medicare and Veterans Affairs coverage—and instead use tax credits to purchase private plans.
Repeal then replace
In recent days, Republicans have indicated that they may not seek to replace the ACA immediately. Instead, some GOP leaders have signaled that they could delay the effective repeal date in order to coalesce around a solid replacement plan.
During a recent interview on CBS' "60 minutes," Ryan said, "We want to make sure that we have a good transition period, so that people can get better coverage at a better price."
Senate Majority Whip John Cornyn (R-Texas) has speculated that Republicans would implement "a three-year transition." He said, "People are being, understandably cautious, to make sure nobody's dropped through the cracks."
However, not all Republicans are on board with the plan of delaying the ACA's repeal while working on a replacement. Rep. Mark Meadows (R-N.C.), who will head the congressional Freedom Caucus, last week said the caucus would mount "major resistance" to proposals that would take up to three years to fully repeal and replace the ACA. Rep. Charlie Dent (R-Pa.), meanwhile, has raised a different concern about passing a repeal bill without a reform package: It "could potentially set up a health care cliff" as insurers flee a dying exchange market.