Republican lawmakers who have spent two years railing against President Barack Obama’s health care law are beginning to devise alternatives so they can be ready if the Supreme Court forces the issue of the uninsured back into the center of political debate.
“If Obamacare goes away, it doesn’t mean that the problem of how you deliver health care affordably and get good access goes away,” Rep. Greg Walden, R-Ore., said. “Those are the issues that are back before us.”
Republicans say they will have to make good on their pledge to replace the health care law if the Supreme Court strikes down any significant parts of it. They remain optimistic about the possibility of a court victory, even as they begin thinking more seriously about what would follow.
“Our wheels are beginning to turn,” said Rep. Fred Upton, R-Mich., chairman of the House Energy and Commerce Committee, which would have a large role in developing Republican alternatives to the Obama health care law.
Beyond some familiar ideas and slogans about “patient-centered health care,” the Republicans concede that they have far to go to come up with a comprehensive policy to fill the gap that could be left by a Supreme Court ruling this summer.
Their approach is likely to set aside universal health insurance coverage as the main objective. Instead, they would focus on lowering costs as “the overriding goal,” said Sen. John Barrasso, R-Wyo., a medical doctor and party spokesman on health issues.
“If you get the costs down, then you get more people with coverage,” Barrasso said.
Republicans are dusting off proposals that date back more than a decade: allowing individuals to buy health insurance across state lines, helping small businesses band together to buy insurance, offering generous tax deductions for the purchase of individual policies, expanding tax-favored health savings accounts and reining in medical malpractice suits.
Many of these ideas were included in a package offered by Republicans in November 2009 as an alternative to legislation pushed through the House by Democrats. The Congressional Budget Office found that the Republican proposal would have reduced health insurance premiums by 5 percent to 10 percent, compared with what they would otherwise have been.
The budget office said that the Republican proposal, offered by Rep. John A. Boehner of Ohio, who is now the House speaker, would have provided coverage to 3 million people, leaving 52 million uninsured.
By contrast, the budget office estimates that the existing law will cover about 30 million people, leaving 26 million uninsured.
Emily S. Porter, a policy adviser to Boehner, said the House had voted 26 times to “repeal, de-fund or dismantle” the new health care law.
A ruling striking down the health law could pose future political problems for Republicans if Americans are still unable to find affordable health insurance or if policies provide inadequate coverage.
Republican lawmakers with experience on health care issues acknowledge that they will have to take action should the health law fall, and planning for the next steps has kicked into high gear. Several Republicans, like Reps. Michael C. Burgess of Texas and Tom Price of Georgia, are developing comprehensive alternatives, and they wish that more of their Republican colleagues would join these efforts.
“The status quo is unacceptable,” said Price, an orthopedic surgeon who is chairman of the House Republican Policy Committee. “Everybody agrees on that.”
In the spring issue of the journal National Affairs, two conservative policy analysts, James C. Capretta and Robert E. Moffit, lay out a road map in an article titled “How to Replace Obamacare.”
“Despite the widespread public antipathy toward the new health care law,” they write, “simply reverting to the pre-Obamacare status quo would be viewed by many Americans, perhaps even most, as unacceptable.”
Upton said Republicans were already looking at which parts of the Affordable Care Act they would preserve. The “easiest one,” he said, is the provision that allows young people up to the age of 26 to remain on their parents’ insurance. That option has proved popular and effective.
A more difficult question for Republicans is what to do about another popular provision of the law, which will prohibit insurers from denying coverage or charging higher premiums to people who are sick or have disabilities. Republicans favor incentives rather than a mandate to carry insurance, and they acknowledge that rates could soar unless they find ways to keep healthy people in the insurance pool.
“We’d have to get that balance right,” Upton said.
Many of the Republican ideas are incorporated in bills introduced last year by Reps. Wally Herger, R-Calif., and Tom Latham, R-Iowa. These bills, like the new law, would prohibit insurers from imposing annual or lifetime limits on spending for covered services. And they would generally prohibit insurers from canceling or rescinding coverage after a person became sick.
Republicans are still weighing whether to allow insurers to continue charging higher rates to women than to men for the same coverage. The new health care law will prohibit such “gender rating,” starting in 2014.
In general, Republicans say, their alternatives would be much less prescriptive than the new federal law, would cost less and would give states more discretion. Republicans are determined to scale back insurance subsidies expected, under the new law, to cost more than $900 billion from 2014 to 2023.
But Rep. Cathy McMorris Rodgers, R-Wash., said her party was willing to put more federal dollars than the Democrats into one type of assistance: high-risk pools, which offer subsidized coverage to people who are unable to obtain private insurance because of medical problems.
Barrasso said such risk pools would be a major part of the Republican response to problems of the uninsured. But, he said, a Republican plan would be careful to limit access to federal subsidies to people with true existing conditions. Annual open enrollment periods, like those held by employer-sponsored health plans, would give qualifying individuals predictable access to the high-risk pools, but people could not enroll when they happen to become sick.
The main feature of a Republican plan could be federal assistance for the purchase of catastrophic health insurance with high deductibles, Barrasso said.
“No one would go bankrupt or lose a home as a result of injury or disease,” Barrasso said. But patients would face more up-front costs and would therefore have incentives to become more discerning consumers of health care, he said.