Republican leaders in the House and Senate, despite the objections of conservative members, are pushing ahead with their plans to include pieces of an Obamacare replacement plan in the repeal bill. We have a pretty good idea of what the most likely pieces will be, but Republicans are still talking about them and there's still time for them to change before House committees take them up after the recess.
With that in mind, here are some of the leading policy ideas based on my conversations with Republican staff members, and the pros and cons of each.
A Medicaid per capita cap. This would limit the amount of federal money each beneficiary would receive from the program, as opposed to the current open-ended spending match. This is also opposed to a block grant, which would give each state a certain amount of money to spend as it pleases.
- Pros: This would save a lot of money — $110 billion over five years, Avalere Health estimates, which could be used to fund the replacement. It's also more politically palatable than a block grant.
- Cons: It doesn't save as much money as a block grant, and its impact is highly dependent on how much money each beneficiary is allotted. More details are also needed to answer the question of whether federal dollars would continue going to the newly enrolled people in the states that expanded Medicaid.
A cap on the tax break for employer benefits. This would set a threshold for employer coverage benefits. Beyond that threshold, employees would pay taxes on those benefits.
- Pros: This also saves a lot of money, potentially hundreds of billions of dollars depending where the threshold is set.
- Cons: It's incredibly unpopular with almost everyone — businesses, labor groups, unions and, importantly, lobbyists who opposed Obamacare's "Cadillac tax" on expensive employer plan benefits. Since the cap is very similar to the Cadillac tax, which was opposed by almost every Republican in Congress, it could be a heavy political lift.
Tax credits for people on the individual market. These would be comparable to Obamacare subsidies, which help low-income people afford premiums on exchanges. Based on what Republican members have proposed in the past, they're likely to be age-based instead of income-based, as the subsidies are.
- Pros: At this point, it's almost a given that Republicans can't strip away all federal assistance from people who rely on it under Obamacare for their health insurance. So providing tax credits avoids a political nightmare.
- Cons: They cost a lot of money and there are bound to be lots of opinions about who should get them and how much they should cost.
Expansion of health savings accounts. This is basically a given, as even conservatives generally want this included in the repeal bill. It'd make it easier for people to put more money into the savings accounts, which are meant to be used for out-of-pocket costs.
- Pros: The idea is to reduce overall costs by making people more personally responsible for their medical spending. If they have more skin in the game, the theory goes, they'll make better decisions.
- Cons: The entire premise of health savings accounts is based on low-premium, high-deductible plans. Low premiums are good, but high deductibles are exactly what Republicans have been saying for years that voters don't want.
The forbidden fruit. These are the policies Republicans would love to include, but Senate rules probably won't let them touch unless they can win some Democratic votes:
- Loosening Obamacare's essential health benefits, which dictate the categories of services insurers must cover.
- Getting rid of other insurer regulations, like actuarial value rules.
- Allowing tax credits to be used outside of the Obamacare exchanges to buy individual coverage.
