President Donald Trump’s newly minted Secretary of Health and Human Services, Rep. Tom Price, R-Georgia, will have his work cut out for him as he now focuses on shepherding Republican efforts to repeal and replace the Affordable Care Act.
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While Trump acted quickly after his inauguration to sign an executive order broadly directing the government to begin scaling back the healthcare law also known as Obamacare, Price, who was confirmed by the Senate early Friday morning, will play the outsized role in Republican plans to unwind the law and craft their own alternative.
Price could either cripple President Obama’s signature healthcare law or keep it on life support long enough for Republicans to coalesce around a replacement plan, according to health care policy experts who outlined a number of possible paths forward.
Price could "pretty much blow up the law" by altering enforcement of the individual mandate, according to Larry Levitt, a senior vice president at the Kaiser Family Foundation. "That authority is a hole they can drive a truck through in terms of weakening the individual mandate."
The individual mandate is one of the centerpieces of the ACA, requiring all individuals to purchase healthcare or else pay a fine. It has been a consistent lightning rod for conservatives who view it as undue federal encroachment on individual choice.
Price and the administration could also drop an ongoing legal appeal of a House Republicans lawsuit that accused the Obama administration of making unconstitutional payments to insurers subsidizing low-income policyholders. Declining to carry on the Obama-era appeal, Levitt said, could "likely lead many insurers to exit the market."
To reign in costs which is vital to conservative critics of Obamacare, another tack the incoming secretary could take would be to alter the benefits provided to policyholders under the law. The ACA defines the categories of benefits provided but defers to HHS on specifics.
Price might limit essential health benefits, and give insurers flexibility within benefit categories outlined in the law to decide what they will and won’t pay for. The law’s mandate requiring insurers to cover contraceptives –- which is controversial among conservatives and something Price has criticized –- could also be targeted.
In addition to policy concerns, Price must also consider how to handle insurers, who have to decide in several months whether to participate in the health care exchanges in 2018.
To that end, Price is expected to work to stabilize the market "while Congress works on legislation," according to Edmund Haislmaier, a senior fellow at the Heritage Foundation who advised the Trump transition team on healthcare policy.
One potential rule to control costs, according to Haislmaier, is a regulation that would make it harder for people to sign up for insurance during special enrollment periods. Insurers believe some people enroll in the periods to game the system by only paying for coverage when they need it, he said.
Another move could widen the difference between how much older and younger insurance customers can pay in premiums. The change, according to Levitt, could leave older customers with higher premiums while lowering them for younger customers.
While Price has laid out his preferences for an Obamacare replacement in legislation introduced in Congress, his past proposals may not be the best indicator of his plans for HHS, said Paul Ginsberg, director of the Center for Health Policy at the Brookings Institute.
"It’s one thing to write a bill you know isn’t going any place because the president is going to veto it, but when you are in position to write legislation or publish regulations that are going to become the law of the land, it might be very different," he said.
Asked Thursday about what pending actions Price is considering, a spokesperson for HHS declined to comment.
But Republicans hope Price’s confirmation will now build momentum for their efforts. Next week, House Republicans will hold briefing sessions for rank-and-file members on several elements of a potential Obamacare repeal bill, which Republicans hope to vote on by the end of March.
But the party still remains divided on their healthcare timeline. Moderate Republicans oppose repealing the law without a clearly articulated replacement proposal, while more conservative members are demanding swift action.
"I think repeal needs to be done within the next two to three months," Sen. Mike Lee, R-Utah, said at a Heritage Foundation event on Wednesday. "Part of getting to next is getting the repeal measure passed."
Others, frustrated with the pace of crafting a new repeal bill, want Congress to send Trump a measure identical to the 2015 bill vetoed by President Obama.
"Our job is to do what we said we would do," Rep. Jim Jordan, R-Ohio, said at the event Wednesday, adding that Republicans should "at minimum" send the 2015 measure -– which could pass in the Senate with only 51 votes under a parliamentary procedure known as budget reconciliation -– to the White House.
After telling the New York Times in an interview last month that Congress should repeal and replace Obamacare "very quickly," Trump has since said that the entire process could take another year.
"I think that yes I would like to say by the end of the year, at least the rudiments, but we should have something within the year and the following year," he told Bill O’Reilly in an interview that aired last Sunday on Fox News.
But even as GOP leaders have downplayed any differences with Trump on policy, his public statements have left some of them confused.
After watching the Fox News interview, Rep. Mark Meadows, R-North Carolina, called an administration official for clarification, he told reporters Wednesday.