Will Trump embrace controversial House GOP health proposals?

After promising for six years to offer a bill to repeal and replace the Affordable Care Act, House Republican leaders last week presented a white paper that House Speaker Paul Ryan called “a real plan, in black and white” to “make healthcare actually affordable.”

But several health policy experts questioned that description, given that the 35-page document contains few details and no numbers describing how much the proposal would cost, how it would be financed or how many Americans would gain or lose health insurance. Past presidential candidates including Barack Obama have laid out similarly vague campaign blueprints. Now, however, Ryan and his colleagues want to replace a law that has expanded coverage to 20 million Americans and helped slow spending growth.

“The difference between putting down principles and writing legislation is that when you write legislation, you have to commit to numbers and details,” said John Goodman, a veteran GOP health policy adviser who helped draft a recent Obamacare replacement bill sponsored by Rep. Pete Sessions (R-Texas) and Sen. Bill Cassidy (R-La.). He nevertheless praised parts of the House GOP package.

Several experts called the House GOP manifesto a rehash of old conservative ideas that Republicans have never seriously tried to implement. “It's no more a plan than saying, 'I'm going to build a house. Here's a stick-figure picture of it, and I can get it for you for next to nothing,' ” said Norm Ornstein, a veteran political analyst at the American Enterprise Institute for Public Policy Research.

There was skepticism about whether presumptive Republican presidential nominee Donald Trump would embrace it, particularly its politically volatile calls to cap Medicaid spending and turn Medicare into a defined-contribution program, exposing future retirees to higher out-of-pocket costs. During the primaries, Trump repeatedly criticized Ryan's past efforts to restructure and cut those programs, and blamed his proposals for Mitt Romney's loss in the 2012 presidential election. Some think Trump is likely to repudiate the Medicare part of the GOP plan, though other parts overlap with his own brief seven-point proposal.

“Ryan's Medicare voucher plan has been shown to be extremely unpopular in polls among people age 50 and older,” said Robert Blendon, a professor of health policy and political analysis at the Harvard School of Public Health.

After repealing the ACA and its coverage mandates, the House GOP plan would offer people who lack public or employer coverage a refundable tax credit in an unspecified amount—adjusted by age, not income—to help them buy insurance. It would limit the tax exclusion for employer health plans; convert Medicaid into a program of capped federal contributions to the states, rolling back the coverage expansion to low-income, able-bodied adults; change Medicare into a “premium support” model while gradually raising the eligibility age to 67; and implement a wide array of standard conservative proposals, such as interstate sales of health plans, expansion of health savings accounts and limits on medical malpractice suits.

It seeks to make the individual market more financially viable for insurers by allowing them to charge older and sicker customers at least five times more than younger and healthier members, rather than the ACA's maximum of three times more.

Goodman said Ryan's group dodged the tough trade-offs. By repealing the ACA's hundreds of billions in taxes, GOP lawmakers would be left with little revenue for funding adequate tax credits to make coverage affordable to those without employer-based plans. “The brutal reality that Republicans have been reluctant to discuss is if you repeal all of Obamacare, there is no money to insure all of the uninsured,” he said.

That may be all right with Ryan, because universal healthcare is not necessarily his goal. “Obamacare is all about quantity, with the goal to get as many people insured as possible,” he said at the plan's roll-out Wednesday. “Our plan is about quality. We'll give (consumers) the tools to get the best care possible. We give you a choice and put you in charge, not the bureaucracy.”

But repealing the ACA taxes would force Republicans to rely on imposing a tax on employer health plans that's more onerous than the ACA's so-called Cadillac plan tax, which Congress postponed with bipartisan support in December.

While the GOP white paper says that “most Americans' plans would not be affected,” Goodman thinks otherwise. “If that tax isn't big, they won't have the money to have a reasonable tax credit,” he said. “And if it's big, it will hit the average worker.”

That could cause political headaches for Republicans in the November elections, and afterward, if they win and try to cap the tax exclusion for employer health plans. Business groups including the National Business Group on Health have already come out against the GOP plan to tax employer health plans.

Another potential political problem for Republicans is their plan would roll back the ACA's popular guarantee that consumers can obtain insurance during an annual open enrollment despite pre-existing medical conditions.

Under the GOP plan, individuals would have a one-time opportunity to enroll without regard to pre-existing conditions, and would be able to keep that coverage as long as they stayed continuously enrolled. But if they discontinued coverage for any reason, insurers could base their premiums on health status. Alternatively, people could receive coverage in state high-risk pools, which the Republican plan would fund with at least $25 billion over 10 years. Experts say that probably wouldn't be enough to provide decent, affordable coverage to the sickest Americans.

“What happens to a working-poor person who loses a job and has to go off insurance for a month or two?” Ornstein asked. “You are putting them back into the situation where for the rest of their lives insurers can deny them coverage.”