WASHINGTON — House Republicans on Monday released long-anticipated legislation to supplant the Affordable Care Act with a more conservative vision for the nation’s health system, replacing federal insurance subsidies with a new form of individual tax credits and grants to states.
Under two bills drafted by separate House committees, the GOP would no longer penalize Americans for failing to have health insurance but would try to encourage people to maintain coverage by allowing insurers to impose a surcharge of 30 percent for those who have
a gap between health plans.
The legislation would preserve two of the most popular features of the 2010 health care law, letting young adults stay on their parents’ health plans until age 26 and forbidding insurers to deny coverage or charge more to people with preexisting medical problems.
It would also target Planned Parenthood, rendering the women’s health organization ineligible for Medicaid reimbursements or federal family planning grants — a key priority for antiabortion groups.
The plan would expand contributions to health savings accounts, which allow people with high-deductible insurance to cover expenses that their plans don’t pay for. It also would allow insurers to charge their oldest customers up to 5 times what they charge young adults. The ACA limits that to 3 times.
The debate, which will start in House committees this week, is a remarkable moment in the annals of government policymaking.
The Affordable Care Act, former president Obama’s signature domestic policy achievement passed only with Democratic support, ushered in the most significant expansion of insurance coverage since the creation of Medicare and Medicaid in the mid-1960s.
Taken together, the bills introduced Monday night represent the first attempt by GOP legislative leaders — and best shot to date, with an ally in the White House — to translate seven years of talking points about demolishing the ACA into concrete action.
At the same time, major aspects of the plans, notably the strategy for tax credits and Medicaid, reflect the treacherous terrain that Republicans face to win enough votes within their own conferences in the GOP-controlled House and Senate.
The bills must address concerns of both conservatives worried about the cost of the overhaul and 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 expanded Medicaid coverage under the ACA.
Senator Rand Paul, Republican of Kentucky, one of at least three conservative senators who oppose giving income-based tax credits, tweeted: “Still have not seen an official version of the House Obamacare replacement bill, but from media reports this sure looks like Obamacare Lite!”
Senator Orrin Hatch, Republican of Utah, chairman of the Senate Finance Committee, wouldn’t rule out changes in the measure by his chamber, where moderates have expressed concerns that it could cost too much and leave too many people without coverage.
And four key Republican senators, all from states that opted to expand Medicaid under the ACA, said they would oppose any plan that would leave millions of Americans uninsured.
“We will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states,” Senators Rob Portman of Ohio; Shelley Moore Capito of West Virginia; Cory Gardner of Colorado; and Lisa Murkowski of Alaska, wrote in a letter to Senate majority leader Mitch McConnell of Kentucky.
The four senators were split on exactly what proposals would meet their standards, but with 52 Republicans, McConnell would not have enough votes to pass repeal without the support of at least two of them.
Democrats, meanwhile, have given no indication that they intend to work with Republicans, and top party leaders decried the GOP plan Monday as a betrayal of everyday Americans. “Trumpcare doesn’t replace the Affordable Care Act, it forces millions of Americans to pay more for less care,” said Senate minority leader Charles E. Schumer of New York.
In particular, the plan to target Planned Parenthood has already generated fierce pushback from Democrats and doubts from some Republicans who have noted that federal funds are already barred from funding abortions and that Planned Parenthood provides routine medical care to millions of American women.
The tax credits outlined by the Ways and Means Committee’s portion of the bill incorporates an approach Republicans have long criticized: income-based aid to help Americans afford health coverage.
Until now, the GOP 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 with which they planned to replace the subsidies should be based entirely on people’s ages and not their incomes. But the drafts issued Monday proposed refundable tax credits that would hinge on earnings as well as age — providing bigger credits for older and poorer Americans.
This big pivot, developed by the Ways and Means Committee under the guidance of House Speaker Paul D. Ryan, Republican of Wisconsin, 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.