Now that House Republicans have upheld their election promise by voting to repeal President Obama's health care law — a largely symbolic act — their real work begins: trying to replace the law with what Majority Leader Eric Cantor calls a "better alternative."
But GOP leaders remain mum on which provisions they intend to replace — or how long it may take to deliver new legislation.
On Thursday, the House directed four committees to begin drafting alternative proposals. The resolution got the support of 14 Democrats.
The committees don't have to meet a deadline for producing results. They do have to meet a set of broad goals handed down from Republican leadership. Many of these goals mirror President Obama's aims for the existing law: allow patients to keep their existing coverage; expand coverage for more Americans; lower insurance premiums by increasing competition among carriers; give states more flexibility to manage Medicare programs.
The GOP leaders' goals — 12 in all — also emphasize their more conservative agenda, such as cutting wasteful government spending, prohibiting taxpayer-funded abortions, promoting economic growth and job creation, and protecting Medicare and other entitlements from insolvency.
Though the Democratic-controlled Senate almost certainly will refuse to take up the House repeal bill, Cantor says Republicans "believe there is a better way for providing options for health care in this country."
So what will the Republican health care plan look like? Here are some of the provisions in the existing law that could be on the table:
1099 Form Requirement: So far, repealing this requirement is the only issue that has gained bipartisan agreement, and a bill to do that — from Rep. Dan Lungren (R-CA) — is expected to pass the House within days. The provision requires businesses to file a 1099 tax form for all vendors whom they pay at least $600 a year. The effort was designed to discourage tax cheats and generate revenue to offset the costs of implementing parts of the law.
Powerful business lobbies have convinced Republican as well as Democratic lawmakers that the requirement would saddle employers with a huge and costly administrative burden and expose them to more, unnecessary IRS audits.
Lungren's bill offers no alternative to replace the $17 billion in revenues which the requirement had been projected to generate.
Coverage For Patients With Preexisting Conditions: One of the Republicans' stated goals is to "provide people with pre-existing conditions access to affordable health coverage." But some skeptics, including supporters of the existing law, note that there is a distinction between providing the chronically ill with access to coverage and actually assuring coverage.
The current health care law's guarantee of coverage for preexisting conditions is probably its most popular provision, and Republicans could face a backlash f they target it.
Medical Loss Ratio: The term refers to the percentage of patients' premiums that insurers spend on actual health care, as opposed to operating costs. The health care law requires insurers to commit at least 80 percent of collected premiums to providing and improving care.
Republican opponents say that large insurance companies already meet the threshold and that the provision unfairly hinders smaller insurers. A bill introduced last year by Rep. John Carter (R-TX) went nowhere but could gain traction among the new GOP majority.
"It would be a tragedy to undo a provision that was worked out by the consumers and the insurance companies that helps patients get better care for their dollar," says Kathleen Stoll, deputy executive director of Families USA, a strong supporter of the existing law.
Defunding The Existing Health Care Law: The law's patient protections are widely popular with Americans, and other provisions, such as tax incentives for employers, have broad Republican support. That makes targeting such measures politically risky. Instead, people on both sides of the debate say Republicans may find it more effective to try to dismantle the law by cutting funds used to implement it.
Republican lawmakers have vowed to order up drastic reductions in spending, as much as $100 billion. One expected target: the Department of Health and Human Services. The agency is responsible for implementing the law, including distributing funds to the states, where most of the work will be done.
The states' most important task will be to create and oversee "exchanges," which are intended to give consumers more coverage options at lower rates while helping smaller insurers compete against larger carriers. Republicans have said they want to expand options in these insurance pools, but critics say any reductions in funding will hamper such efforts.
"States will be in the driver's seat to figure out how this works, and we need to equip them with the resources to do it," says Stoll of Families USA. "This was one of the elements that many Republicans agreed to, so I don't know what else they would replace this with."
Medical Malpractice: This is the GOP's opportunity to enact some degree of tort reform, long a party goal. Republicans blame medical-related lawsuits for driving up health care costs. Republicans, at the behest of physicians, say the current law doesn't go far enough in addressing liability insurance. They want to enact caps on damages and a statute of limitations for filing lawsuits.
Democrats, siding with consumer groups and trial attorneys, have fought such changes. But Obama has said he would consider supporting alternatives that better protect both patients and doctors.
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