House un­veils health over­haul plan

But four Repub­li­can sen­a­tors say they will op­pose re­peal of Oba­macare if it leaves mil­lions unin­sured.

Austin American-Statesman - - FRONT PAGE - By Amy Gold­stein, Mike De­bo­nis and Kelsey Snell Wash­ing­ton Post

House Repub­li­cans WASH­ING­TON — on Mon­day re­leased long-an­tic­i­pated leg­is­la­tion to sup­plant the Af­ford­able Care Act with a more con­ser­va­tive vi­sion for the na­tion’s health care sys­tem, sketch­ing out a sys­tem of in­di­vid­ual tax cred­its and state grants to re­place the cur­rent law.

But GOP lead­ers did not is­sue cost or cov­er­age es­ti­mates for their plan, which is still be­ing re­viewed by non­par­ti­san con­gres­sional bud­getary score­keep­ers, and there were signs Mon­day that fel­low Repub­li­cans could balk if the leg­is­la­tion leaves swaths of the coun­try with­out in­sur­ance cov­er­age.

Four key Repub­li­can sen­a­tors said they would op­pose any new plan that would leave mil­lions of Amer­i­cans unin­sured.

Sens. Rob Port­man, R-Ohio, Shel­ley Moore Capito, R. W.Va., Cory Gard­ner, R-Colo, and Lisa Murkowski, R-Alaska, said they would vote against any re­form bill that fails to pro­tect Amer­i­cans who be­came el­i­gi­ble for cov­er­age un­der the ACA’s ex­pan­sion of Med­i­caid, the gov­ern­ment-run health pro­gram for the poor and dis­abled.

All four sen­a­tors rep­re­sent states that opted to ex­pand their Med­i­caid pro­gram un­der the ACA.

“We will not sup­port a plan that does not in­clude sta­bil­ity for Med­i­caid ex­pan­sion pop­u­la­tions or flex­i­bil­ity for states,” they wrote in a let­ter to Se­nate Ma­jor­ity Leader Mitch McCon­nell, R-Ky.

“Re­form should not come at the cost of dis­rup­tion in ac­cess to health care for our coun­try’s most vul­ner­a­ble and sick­est in­di­vid­u­als. Any changes made to how Med­i­caid is fi­nanced through the state and fed­eral govern­ments should be cou­pled with sig­nif­i­cant new flex­i­bil­ity so they can ef­fi­ciently and ef­fec­tively man­age their Med­i­caid pro­grams to best meet their own needs,” the let­ter said.

With 52 Repub­li­cans, McCon­nell would not have enough votes to pass re­peal with­out the sup­port of at least two of those sen­a­tors.

The sternly worded let­ter was sent as House lead­ers were scram­bling to put fin­ish­ing touches on plans to dis­man­tle the ACA — and be­came the lat­est sign that the chal­lenge may be even greater than Hill Repub­li­cans and Pres­i­dent Trump had re­al­ized.

Al­ready cog­nizant of po­ten­tial op­po­si­tion from both con­ser­va­tive Repub­li­cans leery of high gov­ern­ment costs and mod­er­ates seek­ing to re­tain in­sur­ance cov­er­age for as many Amer­i­cans as pos­si­ble, House Repub­li­can lead­ers were ex­pected to un­veil an ap­proach Mon­day that they have long crit­i­cized: in­come­based aid to help Amer­i­cans af­ford health cov­er­age.

Un­til now, the Repub­li­cans had been in­tend­ing to veer away from the ACA sub­si­dies that help poor and mid­dle-class peo­ple ob­tain in­sur­ance, in­sist­ing that the size of tax cred­its should be based en­tirely on peo­ple’s ages and not their in­comes.

But leg­is­la­tion to re­peal the health care law will pro­pose re­fund­able tax cred­its that would hinge on earn­ings as well as age, ac­cord­ing to three sources fa­mil­iar with the most cur­rent think­ing of the House GOP lead­er­ship.

The shift re­flects two de­sires: to limit the cost of tax cred­its to the gov­ern­ment and to try to avert a pre­cip­i­tous drop in the num­ber of Amer­i­cans who are in­sured. It also high­lights the dif­fi­culty Repub­li­cans face try­ing to ful­fill their prom­ise to re­peal Oba­macare. On the one hand, Repub­li­cans are try­ing to sat­isfy con­ser­va­tives, who have been ral­ly­ing for years to elim­i­nate what they see as the en­ti­tle­ments that the ACA cre­ated. On the other, they are in­creas­ingly wor­ried that push­ing too many Amer­i­cans off in­sur­ance rolls would prompt a po­lit­i­cal back­lash.

Trump, although he cam­paigned on a prom­ise to re­peal the ACA, has said pub­licly he does not want any Amer­i­cans to lose cov­er­age.

The drafts will cul­mi­nate two months of in­tense work by a pair of House com­mit­tees to try to carry out the GOP’s ar­dent de­sire, ever since the ACA was adopted seven years ago with­out Repub­li­can sup­port, to re­place the law with a more con­ser­va­tive set of health care poli­cies. The shift on tax cred­its is an early glimpse at what the leg­is­la­tion will con­tain.

It is un­clear what the size of the tax cred­its will be com­pared to the ACA’s sub­si­dies.

This big pivot, de­vel­oped by the Ways and Means Com­mit­tee un­der the guid­ance of House Speaker Paul Ryan, R-Wis., stems from a com­bi­na­tion of prob­lems that were aris­ing with the idea of age-only cred­its that would have been avail­able to any in­di­vid­ual or fam­ily buy­ing in­sur­ance on their own, no mat­ter how af­flu­ent. Es­ti­mates from con­gres­sional bud­get an­a­lysts and the White House’s Of­fice of Man­age­ment and Bud­get kept show­ing that the cred­its would be both too small to pro­vide enough help to lower-in­come peo­ple and too ex­pen­sive over­all for a GOP de­ter­mined to slash fed­eral spend­ing that the ACA has re­quired.

Ac­cord­ing to the sources, this shift re­flects the treach­er­ous po­lit­i­cal and sub­stan­tive chal­lenges that Repub­li­cans face in try­ing to con­vert anti-ACA talk­ing points into an ac­tual plan, now that they have an ally in the White House.

While the num­ber of Amer­i­cans who can af­ford health in­sur­ance has never been the pri­or­ity for the GOP that it is for Democrats, Trump has made clear that he is sen­si­tive to any changes that would strand large num­bers of peo­ple who gained cov­er­age un­der the ACA. In ad­di­tion, the House lead­er­ship is try­ing to thread its way through a mine­field of con­flict­ing pri­or­i­ties even within the cham­ber’s GOP con­fer­ence.

To win enough sup­port among House Repub­li­cans, the bill has to ad­dress con­cerns of both con­ser­va­tives con­cerned about the cost of the over­haul and wor­ries that it might in ef­fect en­shrine a new fed­eral en­ti­tle­ment, as well as more mod­er­ate mem­bers who want to en­sure that their con­stituents re­tain ac­cess to af­ford­able health care, in­clud­ing those who re­ceived Med­i­caid cov­er­age un­der the ACA.

Lau­ren Aron­son, a spokes­woman for Ways and Means, which is draft­ing the tax pro­vi­sions of the bill, de­clined Mon­day to com­ment on spe­cific pro­vi­sions, say­ing the bill was still be­ing re­vised.

The change in think­ing about tax cred­its has emerged since Fri­day, when a White House meet­ing chaired by Bud­get Di­rec­tor Mick Mul­vaney and at­tended by key GOP con­gres­sional fig­ures was called to fi­nal­ize key pro­vi­sions.

Cer­tain de­tails of the new ap­proach to tax cred­its re­mained un­clear, in­clud­ing whether they would be re­stricted to peo­ple un­der a cer­tain in­come thresh­old per­haps $75,000, ac­cord­ing to the House mem­ber briefed on the plan — or whether the sub­sidy would ta­per off af­ter a spe­cific in­come level but not end en­tirely. Two sources said age would re­main one fac­tor in de­ter­min­ing the size of a per­son’s credit.

At the same time, the shift to take in­come into ac­count could cre­ate a po­ten­tially dif­fi­cult rip­ple ef­fect for Repub­li­cans, who re­gard a re­duc­tion in the fed­eral gov­ern­ment’s role in health care as a cen­tral rea­son to aban­don the sprawl­ing 2010 health care law. One mo­ti­va­tion for the GOP think­ing that cred­its could de­pend only on age was that the In­ter­nal Rev­enue Ser­vice would no longer have needed to ver­ify the el­i­gi­bil­ity of peo­ple for fi­nan­cial help, as it has for ACA sub­si­dies. If in­come is taken into ac­count, the IRS would still need to be in­volved.

The goal of less­en­ing the gov­ern­ment’s role also is be­hind an­other change from the ACA that the Repub­li­can plans en­vi­sion: get­ting rid of the fed­eral re­quire­ment on in­sur­ers to in­clude a min­i­mum set of “es­sen­tial ben­e­fits” in health plans sold to in­di­vid­u­als and small busi­nesses.

Con­ser­va­tives have aired sharp con­cerns about the in­clu­sion of re­fund­able tax cred­its that can be ad­vanced to in­sur­ance providers through the year, call­ing them too sim­i­lar to the ACA’s tax sub­si­dies.

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