A leaked “discussion draft” of House Republicans’ Obamacare repeal-and-replace bill surfaced on Friday. The draft reveals important details about the plan being designed by House GOP leadership. The 106-page discussion draft, dated February 10, was obtained by Politico. It corresponds reasonably closely to the 19-page outline that House GOP leadership leaked on February 16.

The centerpiece of the plan is its attempt to replace Obamacare’s health insurance exchanges with a new program that would provide subsidies for Americans to buy any health insurance plan that is legally available in their state. It would enact two key regulatory reforms of the individual market for health insurance: it would revert back to states the ability to define the “essential health benefits” that insurers must cover, and it would allow insurers to charge their policyholders a much wider range of prices based on age. The plan would also significantly expand the ability of Americans to save money, tax-free, in health savings accounts, and it would make two major changes to the Medicaid program:

  1. It phases down Obamacare’s Medicaid expansion. States would retain the option to maintain a larger Medicaid program, but the federal government would only fund around 60% of the cost, compared to 90% under the ACA. That’s a fair way of balancing the interests of states that expanded Medicaid, and want to maintain that expansion, and states that did not, and don’t want to be punished for their fiscal restraint.
  2. It overhauls the pre-Obamacare Medicaid program, by converting it into a system of per-capita subsidies, in which states would receive a fixed dollar amount for each Medicaid enrollee resident within their borders, which they could then use to fund a safety-net health insurance program that they would design and administer.

. . .

The U.S. House of Representatives is considering a bill that would repeal and replace the Affordable Care Act (ACA) as early as March of 2017, preceding by more than a year one of the  deadlines President Donald Trump has stated for repealing and replacing Obamacare.

House Speaker Paul Ryan (R-WI) has said the House should pass legislation repealing Obamacare before April, and the House Energy and Commerce Committee is one of several aiming to mark up the legislation by March 1, The Hill reported on February 8.

The Trump administration may not be willing to repeal, replace, or repair ACA until the summer of 2018, Trump told Fox News host Bill O’Reilly on The O’Reilly Factor on February 5.

. . .

Vice President Pence forcefully defended on Thursday night the Trump administration’s plans to repeal and replace the Affordable Care Act, saying the law known as Obamacare is a “nightmare” and that the administration is committed to “an orderly transition” to a new health care system. Pence said he and President Trump are committed to giving every American “access to quality, affordable health insurance. . . . We’ll have an orderly transition to a better health-care system that finally puts the American people first,” Pence said.

. . .

As policymakers debate repealing and replacing the ACA, they grapple with how to address the ACA’s “Cadillac Tax.” Rather than repealing the 40% tax on high-cost insurance plans outright, many advocates of “repeal and replace” have proposed replacing it with a limit on the tax exclusion for employer-sponsored health insurance. Doing so would be a wise choice, and limiting the ESI exclusion would both generate significant revenue to pay for an ACA replacement and help to limit the overall growth of health care spending. Other options include capping the income tax exclusion, capping the payroll tax exclusion, and replacing the income tax exclusion with a fixed-dollar credit/deduction.

. . .

As Republicans in Congress look to repeal and replace the ACA, they’re considering a return to high-risk pools like one in Wisconsin, which some considered a national model. The “Health Insurance Risk-Sharing Plan” — which ran from 1979 to 2014, when the federal health law’s exchanges started — was funded through premiums, insurance company assessments and reduced payments to providers. “Pooling the high-risk individuals together and managing their needs separately was a huge factor in the state’s success in offering a competitive insurance market,” J.P. Wieske, the state’s deputy insurance commissioner, told the House Energy and Commerce Committee this month.

. . .

Let the states derive their own health care solutions, particularly when it comes to cost containment. That’s why we may need to look to six states that are aggressively working to contain costs. The Florida, Georgia, Alabama and Tennessee legislatures are considering a proposal to eliminate defensive medicine by abolishing each state’s medical malpractice system and replace it with a no-blame model similar to workers’ compensation. Two other states are also examining the concept. When doctors are no longer the target of litigation, they would be less likely to order unnecessary tests, medications and procedures.

. . .

Arizona Gov. Doug Ducey heads to Washington this week to attend the Conservative Political Action Conference. The Washington Examiner asked him to preview his main priorities regarding Obamacare replacement and what they should know about Arizona’s healthcare challenges.

He said, “The damage from Obamacare is clear: Insurance markets have been wrecked; premiums have soared; and promises, such as “you can keep your doctor,” have been broken. That’s what happens when one party imposes a one-size-fits-all solution on one-sixth of the country’s economy without even bothering to read the bill. Congress should do the opposite of what occurred in 2010: It should seek to expand choices for consumers, not limit them; it should encourage innovation in the states, not stifle it; and it should read the bill and understand the implications of what it’s passing instead of simply hoping for the best despite ample evidence to the contrary.”

. . .

Every day brings a new story about Republicans in disarray, the “mirage” of the GOP’s reform and the impossibility of change. The reality is that Congress is on schedule, progress is underway, and the many potential problems are avoidable.

Behind the scenes, members and staff are being briefed on options and the House will release a consensus proposal after the Presidents Day recess. The details matter and are under discussion, but the outlines are emerging. Congress will use the reconciliation budget maneuver to bypass the Senate filibuster and pass a version of the 2015 repeal bill that President Obama vetoed. This time they’ll incorporate as many replacement components as the rules allow to bring more predictability to insurance markets.

. . .

The combination of high-deductible insurance with Health Savings Accounts (HSAs) is central to a market-driven reform of U.S. health care. There is, however, a problem with existing HSA policy that must be fixed if HSAs are to reach their full potential in improving the efficiency of health care arrangements: As currently structured, HSAs are not built to provide easy access to care from well-organized systems of health care. Rather, HSA enrollees buy services on a fee-for-service basis, which is, in most cases, a much less efficient way of getting needed care. The rules governing HSAs should be modified to allow account holders to buy access to care from integrated care systems on a fixed-fee basis.

. . .

The Trump administration proposed new rules on Wednesday to stabilize health insurance markets roiled by efforts to repeal the ACA, by big increases in premiums and by the exodus of major insurers. The move came a day after Humana announced that, starting next year, it would completely withdraw from the public marketplaces created under the ACA. The proposed rules, backed by insurance companies, would tighten certain enrollment procedures and cut the health law’s open enrollment period in half, in hopes that a smaller but healthier consumer base will put the marketplaces on sounder financial footing and attract more insurance companies in states with limited choices.

. . .