As Trump promises swift action, GOP still struggles with Obamacare replacement

In his first tweet of the day early Friday, President Donald Trump claimed that “the repeal and replacement of ObamaCare is moving fast!”

Not that fast, apparently.

Republicans in Congress still have not figured out exactly what that replacement will look like. Trump’s new secretary of health and human services, Dr. Tom Price, met with House Republicans Thursday and general ideas were discussed, but consensus on specifics remains elusive.

One thing Republicans do agree on is that action is needed urgently and the system established by the Affordable Care Act is disastrous.

“It has become increasingly clear that this law is collapsing,” House Speaker Paul Ryan, R-Wis., said at a news conference Thursday. “People's premiums are getting higher and higher. Their deductibles are soaring. And their choices are dwindling to the point that so many families have no choice at all.”

Earlier this week, one major insurer, Humana, announced it will not participate in individual health insurance markets in 2018, and the head of another, Aetna, claimed the system is in a “death spiral.”

“The status quo is unsustainableit’s crashing,” Senate Majority Leader Mitch McConnell, R-Ky., told reporters Friday, recalling that former President Bill Clinton called the current system “the craziest thing you’ve ever seen.”

Trump told reporters Thursday that an initial plan to replace Obamacare will be submitted in early March. However, CNN reported that Republicans on Capitol Hill have no idea what his plan is, or if he is working on one at all.

Trump has recently promised that insurance will be “far less expensive and far better” under the replacement and it will provide “coverage for everyone.” That guarantee diverges from the goals of many in Congress.

Talking points distributed to members and obtained by Politico seek to arm them with negative statistics about the Affordable Care Act and substantive details of a replacement before they head to potentially heated town halls in their home districts next week.

“We have the responsibility to prevent a real train wreck for millions of Americans. And not only can we solve this problem, we must solve this problem,” the document states.

The talking points are based on the House GOP “Better Way” agenda, but a group of conservatives led by Sen. Rand Paul, R-Ky., and Rep. Mark Sanford, R-S.C., laid out their own proposal this week. Secretary Price authored a replacement bill in 2015 when he was in the House. All of those options and more are still on the table, and the Kaiser Family Foundation has created an interactive guide for patients to compare them to each other and to the existing law.

Though the particulars of the plans do vary, there are recurring themes.

A Republican plan will likely replace the ACA’s subsidies for low income families with refundable tax credits that are based on age rather than income. The latest proposal does not specify the amount, but previous plans have fallen short of what many poor families would need to afford their premiums.

Health savings accounts are also a significant element. Republicans want to allow workers to set aside more tax-free funds to pay for their health care, but critics argue such mechanisms only benefit those earning enough to be able to afford saving more of their money.

The plans also attempt to deal with the ACA’s Medicaid expansion, which is responsible for a large percentage of the increase in the insured since 2010. Many Republican-run states refused to accept the expansion, but more than a dozen GOP governors and several vulnerable senators represent states that did and fear the blowback if the coverage is taken away.

Ryan was particularly vague on this front at his Thursday news conference. He said House Republicans are “working with governors to come up with solution so that whether a state chose to take the money or didn’t, going forward as we give states more control, as we advance the principle of federalism by giving states more control over Medicaid so they can have innovative reforms, that we do it in a way that doesn’t disadvantage either side of that coin.”

One thing that is clear is that, like the ACA that was passed with only Democratic votes, whatever plan takes shape will not reflect bipartisan priorities.

“It’s clear that in the early months it’s going to be a Republicans-only exercise,” McConnell said. “We don’t expect any Democratic cooperation on the replacement of Obamacare.”

Rep. Marsha Blackburn, R-Tenn., told WZTV earlier this month that the replacement will involve three phases. Some changes can be made by Price and HHS administration without congressional approval. Budget-related measures can be passed easily with a simple majority in the Senate through reconciliation.

Some significant elements of the ACA, like the minimum standards it set for coverage, can only be repealed through the regular legislative process, though, and that will require 60 votes in the Senate.

Appearing on CNN Friday, Blackburn struggled to explain exactly how Republican proposals like larger health savings accounts and selling insurance across state lines will actually reduce health care costs.

“It brings down costs because you change the way an individual looks at the marketplace and utilizes health care,” she told a skeptical Chris Cuomo. “You bring transparency to bear so that people know what it’s costing.”

Sandy Ahn, an associate research professor at the Center on Health Insurance Reforms at Georgetown University, said the situation is not nearly as dire as Republicans claim. Some experts have predicted the exchanges will be profitable for insurers in 2017 and the recent double-digit increases in premiums were a one-time correction.

“I think a lot of the opponents of the ACA are saying the marketplaces are in a death spiral, but that’s not the case,” she said.

She also questioned whether any of the measures proposed by Republicans can offer coverage to as many people as the ACA at better prices. Health savings accounts do little for low income families and tax credits may disproportionately benefit higher income workers.

Plans to replace the ACA’s protection of patients with pre-existing conditions often involve high-risk pools, but Ahn said those have been unsuccessful in most states that tried them. She suggested bringing back the reinsurance program that compensated insurers for taking riskier patients and reviving efforts to boost enrollment in the exchanges.

“If you want to stabilize the risk pool, you want to make it as big as possible,” she said.

Many health care experts have warned of dire consequences if whatever plan is implemented to replace the ACA falls short. A Commonwealth Fund study found repealing the ACA’s subsidies and Medicaid expansion could cost 2.6 million jobs in 2019.

Thomas Huelskoetter, a policy analyst at the liberal Center for American Progress, claimed in a blog post that the plan outlined for House Republicans Thursday “would leave millions uninsured or with worse coverage than under the ACA and would significantly raise many consumers’ out-of-pocket costs.”

Conservatives are understandably more optimistic about the Republican approach.

“Congress must focus on the fundamentals: equalizing the tax treatment of health insurance; restoring commonsense regulation of health insurance; and addressing the serious need for reform in Medicare and Medicaid by adopting policies that give individuals control over their health care. High quality health care means all Americans should be free to choose a health care plan that meets their needs and reflects their values,” analysts at the Heritage Foundation wrote in a report last week that reflected many of the same priorities as the House talking points.

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