Yet, the new House speaker intends to back a “bold alternative agenda,” and he committed to unveiling a replacement plan in his first major policy address.
“There are many things to do, but most urgent is to repeal and replace Obamacare,” he told an audience at the Library of Congress on Dec. 3. “We think this problem is so urgent that, next year, we are going to unveil a plan to replace every word.”
Since then, Ryan’s office seems to be distancing itself from the process of assembling an alternative. (Notice Ryan did not commit to holding a vote on any plan.)
“As the speaker has said many times, committees, not leadership, will be taking the lead on policy development,” said Ryan spokeswoman AshLee Strong in response to an inquiry. “The next step will be forming committee-led task forces that will hold listening sessions with Republican members … The task forces will then develop the specific policy.”
Strong pointed to Ryan’s comments earlier this month that House Republicans would have a “complete agenda” in place by the time the GOP chooses a presidential nominee. Ryan has not committed to putting the agenda in legislative language, however.
Some health care experts are dubious.
“I doubt they will release a plan,” said Timothy Jost, a health care expert and law professor at Washington and Lee University who supports the ACA.
“They have done just fine running against the ACA and any actual proposal pins them down to ideas they will have to defend. It will also, I think, reveal how threadbare their proposals are — mostly warmed over ideas they have pushed for years and have never really worked when tried.”
Even conservative health care policy wonks were skeptical that Republicans will rally behind a single proposal this year.
“I’d bet on Ryan himself endorsing some sort of specific health care plan by the end of the year,” said Philip Klein, managing editor of the Washington Examiner and author of a book, “Overcoming Obamacare.” “I’m less convinced that he’ll be able to get House Republicans to agree on one single plan, because there are a still important differences among Republicans that are unlikely to be resolved in an election year.”
Even if Republicans unite around a plan, it might not get a vote during a year dominated by the election.
“It doesn’t seem too tough to develop another such plan,” said Doug Holtz-Eakin, president of the American Action Forum, a right-leaning think tank, and former director of the Congressional Budget Office. “But given the short calendar, I’m not as optimistic that they will actually pass it in the House.”
The shape of a GOP health care alternative, if it does happen, is likely to reflect Republican proposals that have been debated for years now. And there are a number of significant hurdles to repealing the current system.
Every Republican health care proposal guts central components of the ACA’s structure, including its individual mandate to purchase health insurance, its expansion of Medicaid, and its insurance exchanges, where premium subsidies are available to people with lower incomes. These changes would prove chaotic for the health care system, particularly just a few years after the ACA overhauled insurance markets and introduced new benefits now used by millions of people.
Without delving into specifics, Ryan indicated Dec. 3 he supports an approach taken by House Budget Committee Chair Tom Price (R-Ga.) in his Empowering Patients First Act, one of several Republican health care proposals floating around Capitol Hill without the party’s full support.
Price’s plan would deregulate the health insurance market compared with the status quo by no longer requiring health plans to cover benefits deemed “essential” under Obamacare. The plan would use refundable tax credits to help people better afford health insurance premiums in the absence of Obamacare’s exchanges and premium subsidies. The size of the credit would be based on age, not income level, under the bill.
“I’ve long believed we should offer an individual tax credit to help people pay for premiums — giving more to the old and sick,” Ryan said in his December speech. (In this comment, Ryan seemed to turn away from the model proposed by the Republican Study Committee, which wants to create a standard deduction for health insurance after repealing Obamacare.)
Price would provide individuals with a one-time tax credit of $1,000 to use on health care not covered by their insurance. Like other Republican plans, his would allow insurance companies to sell policies across state lines. It would also allow people to opt out of government programs like Medicare and purchase private coverage instead.
Not all Republicans support the plan. Some disagree with the idea of providing tax credits to encourage people to buy coverage, seeing the program as a new entitlement. (This was Bobby Jindal’s rationale when he criticized a health care plan from Scott Walker, who would also use tax credits to incentivize health coverage.)
What about the problem of insurers discriminating against people with pre-existing conditions?
This is prohibited under the ACA, necessitating the law’s requirement that everyone buy health insurance or pay a fine. The Price plan would do away with this system, and instead use federal grants available to support high-risk insurance pools (or similar alternatives) for people with pre-existing conditions.
Democratic lawmakers and liberal advocacy groups charge that plans like Price’s would lower the number of Americans with health insurance. The Obama administration announced Jan. 7 that 11.3 million people had signed up for Obamacare’s exchanges during the current enrollment cycle. It is unclear how many of these people would stay covered under Republican plans.
ACA supporters argue that Price’s proposal, along with other GOP plans, does not adequately replace crucial protections contained within the ACA, particularly for low-income or sick people.