No clear health-care plan

RE­PEAL EF­FORT BE­GINS Hard work will be find­ing al­ter­na­tive

The Washington Post Sunday - - FRONT PAGE - BY AMY GOLD­STEIN gold­steina@wash­post.com Staff writer Paul Kane con­trib­uted to this re­port.

House Repub­li­cans must forge their own path as re­peal ef­forts be­gin.

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 ‘ Obama care’ 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 mar­ke­to­ri­ented 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?”

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