GOP lacks clear health-care plan

By Amy Goldstein
Washington Post Staff Writer
Saturday, January 15, 2011; 5:51 PM

With the House preparing to vote this week on whether to repeal the health-care law, the chamber's new Republican majority is confronting a far more delicate task: forging its own path to expand medical coverage and curb costs.

The House's GOP leaders have made clear that they regard the repeal vote, scheduled to begin Tuesday, as the prelude to a two-prong strategy that is likely to last throughout the year, or longer.

They intend to take apart some of the sprawling law, which Democrats pushed through Congress last year, piece by piece before major aspects of it go into effect. At the same time, Republicans say, they will come up with their own plan to revise the health-care system, tailored along more conservative lines.

On the cusp of undertaking this work, the GOP has a cupboard of health-care ideas, most going back a decade or more. They include tax credits to help Americans afford insurance, limiting awards in medical malpractice lawsuits and unfettering consumers from rules that require them to buy state-regulated insurance policies. In broad strokes, the approach favors the health-care marketplace over government programs and rules.

House Republicans have termed their strategy "repeal and replace." But according to GOP House leaders, senior aides and conservative health policy specialists, Republicans have not distilled their ideas into a coherent plan.

"Replacing 'Obamacare' is not something we can accomplish overnight," said Rep. Fred Upton (R-Mich.), the new House Energy and Commerce Committee chairman, using the GOP's pejorative term for the new law. "We want to get it right, and on complex issues like these with huge consequences for the economy and jobs and spending, that means it may take time. But mark my words, we will get this done."

Compared with similar efforts in the past, Republicans acknowledge, their work will be complicated by a fiscal and political climate in which a reduction in the near-record federal budget deficit is a priority. "The biggest difference in health care is, we are bankrupt up here, and states are bankrupt," said one senior House aide, who spoke on the condition of anonymity about the chamber's preliminary thinking.

In the absence of a plan, Republican leaders nevertheless are eager to convey that they have ideas about health care - and are not merely trying to knock down those of the Democrats. As a result, they have drafted a resolution to accompany the repeal legislation. It lays out broad, long-held GOP health-care goals, but no specifics, and directs four House committees to develop proposals.

Even Democrats acknowledge that the GOP has enough votes to pass the repeal measure and the resolution. But there is no evidence that such victories would spill over into the Senate, where Democrats remain in the majority. And President Obama, for whom health-care reform is a major domestic accomplishment, will be in office at least two more years. The White House has said he would veto any repeal.

Similarities, differences

House committees plan to conduct hearings to single out parts of the new law for criticism - starting within weeks with those pieces they say could harm jobs - and to develop their own proposals.

A particular challenge for Republicans is how to handle the possible effect of removing the law's requirement, as they have vowed to do, that most Americans carry health insurance starting in 2014, said Mark B. McClellan, director of the Brookings Institution's Engelberg Center for Health Care Reform, who held several senior health-care positions in the George W. Bush administration. He said the GOP would need to be careful to find other ways to deter people from drifting in and out of the insurance market, depending on whether they need care.

The clearest signs of recent Republican preferences can be gleaned from a remnant of the last health-care debate: a House GOP proposal drafted in late 2009 to try to counter the Democratic legislation that became law last March. Rep. Dave Camp (R-Mich.), the new Ways and Means Committee chairman, was a chief co-sponsor of that alternative.

A few parts of the GOP proposal overlap with provisions of the new law. Among them are high-risk pools - special coverage for Americans who are rejected by insurance companies because they already are sick.

Like the new law, the GOP version also would have allowed young adults to remain on their parents' insurance policies longer and would have tried to give consumers more information in choosing insurance.

"Some of the ideas . . . are not intrinsically Republican or Democratic," said Douglas J. Besharov, a public policy professor at the University of Maryland. "It's their implementation that's left or right."

Other elements of the GOP proposal would have been major departures from the new law. The plan would have let people buy insurance across state lines - a key plank of conservatives on health policy. The idea is to help drive down insurance prices by giving people access to less generous and less expensive insurance policies sold in states whose regulators require fewer medical benefits.

The Republican plan also would have expanded the use of "health savings accounts," another approach long favored by conservatives that lets people set aside money for future medical expenses on a tax-free basis, in combination with bare-bones insurance policies.

In addition, it would have restricted awards in successful medical malpractice lawsuits and would have given states financial help to devise market-oriented ways to expand coverage and lower the price of insurance.

Many of these ideas date back more than a decade to the days when Rep. Bill Thomas (R-Calif.) was the Ways and Means chairman and a powerful, self-assured force in conservative thought on health policy.

"There is nobody quite like Bill up there anymore," one conservative health policy specialist said. "He was bold."

Last time around

The range of current thinking in the House is not entirely clear, with 87 Republican freshmen and nearly half the members of the influential Ways and Means panel new this year.

In the last Congress, the most fully developed Republican proposal came from Rep. Paul Ryan (Wis.). It was controversial even within the GOP.

Part of a broader plan to reduce the deficit, Ryan's approach would diminish the nation's reliance on employers to provide health coverage by removing the tax preferences companies receive for insuring their workers. Instead, the government would give Americans tax credits to shop for insurance on their own. Ryan's plan also would redefine the nation's large public entitlement programs: Medicaid for the poor and Medicare for older Americans. Except for those now on Medicare or close to being eligible, the program would switch to giving people a "defined contribution" - that is, a federal payment toward their coverage - rather than the traditional "defined benefit," guaranteeing specific coverage no matter how much it costs.

Just 14 Republicans co-sponsored Ryan's plan in the last Congress. Ryan is the new chairman of the House Budget Committee, and it is unclear whether that perch will prompt him to refine his thinking - or give him more leverage for his ideas.

"Other than Ryan, what you have is this conglomeration of bills that, when they were in the minority, [Republicans had] no hope it was going to go anywhere," said Joseph Antos, a health-care scholar at the American Enterprise Institute. "The challenge now is, what is the bill? What is the idea?"

Staff writer Paul Kane contributed to this report.

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