Republicans in Congress have been saying for months that they are working on a plan to repeal and replace Obamacare in the Trump era. Now we have the outline of that plan, and it looks as if it would redirect federal support away from poorer Americans and toward people who are wealthier.

A white paper drafted by House leadership and the staff of the House and Senate committees that oversee health policy details a structure that could replace large sections of the Affordable Care Act. Crucially, the proposal largely contains provisions that could be passed through a special budget process that requires only 50 Senate votes, and fulfills President Trump’s promise that the repeal and replacement of the law would take place “simultaneously.”

The plan would make major changes in how health care is financed for Americans who don’t get coverage from work. It would greatly expand the number of Americans who could benefit from federal help in buying health insurance, but it would change who benefits most from that support.

Obamacare, as the A.C.A. is known, extended health coverage to 20 million Americans through two main mechanisms. It expanded Medicaid coverage to Americans below or just above the poverty line in states that participated, and it offered income-based tax credits for middle-income people to buy their own insurance. Obamacare was a redistributive law, transferring money from rich to poor.

The Republican plan would alter both of those programs, changing the winners and losers. It would substantially cut funding for states in providing free insurance to low-income adults through Medicaid. And it would change how tax credits are distributed by giving all Americans not covered through work a flat credit by age, regardless of income.

That means that the biggest financial benefits would go to older Americans, like, say, Secretary of State Rex Tillerson. If he didn’t have a job in the Trump cabinet and access to government coverage, a 64-year-old multimillionaire like him would get the same amount of financial assistance as someone his age, living in poverty, and he would get substantially more money than a poor, young person.

http://www.sacbee.com/opinion/op-ed/soapbox/article132714019.html

The new administration and Congress are under intense pressure to craft a market-based alternative to the Affordable Care Act. It won’t be easy. To achieve the financial stability required to make the market work, reformers should heed some important lessons from California.

Health plans and risk-taking medical groups essentially made a “deal” with Congress to participate in the ACA. They agreed to cover applicants with pre-existing conditions without charging higher premiums in return for: an expanded individual market driven by a federal mandate that everyone buy insurance; premium and cost-sharing subsidies financed by insurers and the government; and three federal risk-mitigation programs to help stabilize the new marketplaces.

http://www.healthcaredive.com/news/outline-of-gop-plan-to-replace-aca-has-few-surprises/436472/

Dive Brief:

• An outline of the Republican plan to replace the Affordable Care Act was leaked Thursday after a meeting among Senate Republicans, The New York Times reports.
• The document is a blueprint modeled after the House Republican’s plan called A Better Way, with age-based tax credits to help people buy insurance and more reliance on health savings accounts.
• President Donald Trump said in a tweet early Friday that repeal and replace of the ACA is “moving fast” and House Speaker Paul Ryan said earlier this week he expects legislation to be introduced possibly as early as next week.

Dive Insight:

The GOP plan leaked Thursday contains few surprises but does leave out some key areas. It makes no mention of changing Medicare into a premium support plan, which Ryan has supported but Trump has been wary of.

The plan also makes no mention of how it would be paid for. Bloomberg has reported, however, that the GOP may be considering capping the tax break on employer-sponsored health insurance. This would be a major tax policy change. Policy analysts tend to support the idea but it could be a tough sell for lawmakers eyeing reelection.

The plan does address Medicaid, and essentially guts the expansion put forward by the ACA. It would roll back the generous cost sharing for states that expand eligibility and give states either a fixed sum per beneficiary or a block grant. Either way, far fewer people would be covered, leading to more uninsured and without access to care.

This could be unpopular, even among fellow Republicans. A handful of GOP governors in expansion states have said the move has improved healthcare access and their state’s economy.

Congress returns Tuesday and Republican leaders will push for legislation to be introduced as soon as they receive more guidance from the Congressional Budget Office, which is scoring some of their proposals.