House Republicans came out of a highly anticipated meeting on health care Thursday morning with some new details on the options GOP leaders are considering to replace the Affordable Care Act, but not with the fully formed plan that those leaders and President Donald Trump have promised.
The meeting in the Capitol basement included presentations from leaders of key House committees and Health and Human Services Secretary Tom Price, and it was intended to give lawmakers more details ahead of a week-long recess where many of them will be meeting constituents eager for details on what will replace the health-care law they have pledged to repeal.
According to numerous lawmakers and aides in the room, as well as a policy memo distributed afterward, the House leaders laid out elements of a repeal-and-replace plan - including long-standing Republican concepts like health savings accounts, tax credits and state high-risk pools for the chronically sick. But they did not detail how those elements would fit together or get passed into law.
"It's sort of a smorgasbord right now," said Rep. Daniel Webster, R-Fla.
House Speaker Paul Ryan, R-Wis., told reporters Thursday that legislation to overhaul the ACA would be introduced later this month, after lawmakers return from the recess. He pointed to recent news that major insurer Humana would stop selling individual plans on ACA-mandated state marketplaces.
"It is getting worse by the day, and it will keep getting worse unless we act," he said. "We need to rescue people from this collapsing law, and we need to replace it with a true patient-centered system."
What was clear Thursday is that Trump intends to take a hands-off approach to overhauling the health-care system - for now, at least. He had earlier pledged, including to The Washington Post shortly before his inauguration, that he had a health-care plan "very much formulated down to the final strokes" to be introduced once Price was confirmed. At a news conference Thursday, Trump again said his plan was in the "final stages" and would be submitted to Congress in March.
The problem for the president and Republicans is that the ideas presented to lawmakers Thursday are sparking major divisions among their party. Medicaid, for instance, is a flash point between hard-line conservatives who want to significantly roll back federal spending and members from states that took advantage of the ACA's Medicaid expansion and are now wary of reducing coverage.
Another significant division is over how to structure tax breaks to encourage individuals to buy insurance plans. Ryan and other House leaders say they favor refundable tax credits, while many conservatives say they prefer less expansive - and expensive - tax deductions.
Rep. Raúl Labrador, R-Idaho, who backs deductions, said of the tax-incentive debate: "There's no consensus. We had two minutes to discuss it."
Even some of the committee leaders who are crafting the health-care legislation acknowledged after the meeting that plenty remains unresolved.
"We're talking different options," said Rep. Patrick Tiberi, R-Ohio, chairman of the Ways and Means subcommittee on health. "We are working together - this is not top-down; this is bottom-up."
Asked when legislative text would be released, Tiberi said, "To be determined."
Price, who served in the House until his confirmation last week and penned an ACA alternative plan, told members that Trump is "all in" on repealing the Obama-era law and replacing it "concurrently." But he indicated that the House would take the lead in that process and did not endorse specific overhaul elements. He also gave only a broad overview of regulatory steps he would be taking as secretary to address turmoil in the insurance markets.
At one point, according to an attendee of the party meeting, Price quipped that he used to be frustrated when he was a congressman and Cabinet secretaries gave vague answers to his questions. Now, he said, as secretary, he is obligated to be vague.
Ryan and other lawmakers acknowledged that important details remain unknown - including, crucially, how much the Republican health proposals will cost. Ryan said the Congressional Budget Office and the Joint Committee on Taxation are "scoring" the fiscal effect of the various elements.
The release of cost estimates could widen fissures between hard-line conservatives, who wish to keep federal spending to a minimum, and the rest of the House GOP, who seem to believe spending will be necessary to prevent turmoil in the insurance markets.
"We did learn a lot," Rep. Pete Sessions, R-Texas, the House Rules Committee chairman, said of the meeting. "They did not overlay the money, and that's the big question."
Rep. Kevin Brady, R-Texas, the chairman of the Ways and Means Committee, said he discussed options for individual tax credits and a possible expansion of the existing system of health savings accounts that allow individuals to set aside untaxed income for health care.
"We're really looking at a whole range of options," he said.
Rep. Greg Walden, R-Ore., chairman of the Energy and Commerce Committee, presented options to overhaul the Medicaid system, but said no final decisions were made.
Members discussed whether to institute per capita limits on how much money the government would put into the Medicaid system or to shift to a "block grant" where states receive a lump sum of money to distribute as they see fit.
The memo distributed to lawmakers says that states would be able to choose whether to receive a block grant or remain in the traditional, capped program. But the states that participated in the ACA's Medicaid expansion would eventually lose out on much of the federal funding they have used to cover millions of Americans.
Under the ACA, the federal government covers more than 90 percent of the costs to insure the expanded Medicaid population. The GOP blueprint suggests slowly stepping down that percentage over an undetermined period of time, after which states "would be reimbursed at their traditional match rates for these beneficiaries." Those rates vary from state to state; some receive as little as 50 percent, meaning individual states could lose hundreds of millions of dollars a year in federal reimbursements under the GOP proposal.
Rank-and-file members leaving the meeting largely said they felt reassured about the path forward. But most said what was presented Thursday did not constitute a complete plan.
"I think there's a road map," said Rep. Bill Huizenga, R-Mich. "Whether we're going to be taking a six-lane highway or a four-lane highway, I don't think that's been determined yet, but we know the direction that we want to go."