In his carefully calibrated testimony before House appropriators, Health and Human Services Secretary Tom Price made one thing clear Wednesday: The administration is still intent on dismantling parts of the Affordable Care Act even if Republicans lack the votes to rewrite it.
Time and time again, Price invoked the pledge he has made repeatedly to lawmakers since President Donald Trump selected him for his post. "What we're committed to is making sure the American people have access to affordable coverage," he told Rep. Rosa DeLauro (Conn.), the top Democrat on the Appropriations subcommittee on labor, health and human services, education, and related agencies.
But under intense questioning from Democrats, Price outlined how his department could make insurance plans cheaper by scaling back several federal mandates, including what the ACA currently defines as "essential benefits" in coverage. And he refused to say whether the administration will keep providing cost-sharing subsidies for insurers participating in the federal marketplace. The multibillion-dollar infusion is critical to maintaining the system's stability, insurers say.
At one point, DeLauro asked Price whether the administration wanted to "repeal or strengthen and improve" the 2010 health-care law.
"We believe that the current law has harmed many individuals," the secretary said.
"So you will continue to move at repeal, is what I gained from that conversation," she replied.
Even before House Republicans withdrew legislation last week that would have jettisoned key aspects of the ACA, White House officials had pledged to pursue a "phase two" through executive action. This stage could cover everything from how aggressively the government promotes enrollment under the law to what sort of financial support it gives to prop up the ACA marketplace.
While House Speaker Paul Ryan, R-Wis., is encouraging factions from the GOP's moderate and conservative wings to negotiate a possible health-care compromise, several individuals briefed on the leadership's plans said there is no immediate interest in bringing a revised bill up for a House vote.
Ryan said in a CBS News interview Wednesday that if Republicans don't unite, Trump would "just go work with Democrats to try and change Obamacare."
"That's hardly a conservative thing," he said.
Insurers are particularly anxious to know whether the cost-sharing subsidies that help lower-income people to afford their out-of-pocket costs, which House Republicans have challenged in court as illegal, will continue. According to the Congressional Budget Office, those federal payments will total $7 billion this year and $10 billion in 2018.
Price noted that as secretary he is now the named defendant in the lawsuit, and "I'm not able to comment."
AshLee Strong, a spokeswoman for Ryan, said the House GOP is "actively working with the administration" on options for resolving the suit and possibly appropriating the subsidies. "No decisions have been made," she said.
Rep. Tom Cole, R-Okla., who chairs the panel before which Price testified Wednesday, said he was open to providing the funds but that it would have to be a House leadership decision. "It's probably the right thing to do, I think. Otherwise you're going to have insurance companies exiting the market," Cole said.
Michael Adelberg, a health-care principal at FaegreBD Consulting, considers the subsidies "the single most important action" the administration can take to stabilize the marketplace. Refusing to pay them will bring "significant premium increases," Adelberg said in an email. "Some insurers will drop out, and the remaining insurers will have to seek large rate increases."
Molina Healthcare chief executive Mario Molina said recently that the cost-sharing funds are a major uncertainty hanging over his company's ability to participate in the marketplaces going forward. Another is enforcement of the individual mandate that compels Americans to provide proof of insurance on their taxes.
"If the president chooses not to enforce the mandate, he's going to drive up the cost for many, many people," Molina said, noting that premiums would probably rise 15 percent if it is not enforced. If cost-sharing reductions are eliminated, he added, premiums would rise an additional 10 to 12 percent.
Price indicated Wednesday that the individual mandate remained in place, telling the panel, "So long as the law's on the books, we at the department are obliged to uphold the law."
But the president offered leeway in enforcing the mandate hours after his inauguration in January, when he signed an executive order instructing agencies "to minimize the unwarranted economic and regulatory burdens" associated with the ACA, in part by acting to "waive, defer, grant exemptions from or delay" its rules.
Republicans urged the secretary to use the available levers available to pare back requirements that have led to more comprehensive - and costly - health plans under the ACA.
"You do have the ability to make regulatory changes that would dramatically lower the cost of insurance for Americans?" asked Rep. Andy Harris, R-Md.
"Fourteen hundred and forty-two times the ACA said 'the secretary shall' or 'the secretary may,' " Price replied.
On several occasions, Price suggested he may define how much insurers would have to cover under the category of essential benefits, which includes maternity and newborn care as well as substance abuse and mental-health treatment.
Asked by Rep. Nita Lowey, D-N.Y., whether maternity care "should be a covered benefit under federal law," Price said consumers should make that decision in the coverage they choose, "not the kind that the government forces them to buy."
When Lowey pressed him on whether women should be able to access contraception without having to pay an insurance co-pay - another ACA mandate - Price made the same point.
"Again, this is one of those areas where we think individuals ought to have access to the kind of coverage that they want, not the kind of coverage that the government forces them to buy," he said.
The administration is likely to face resistance from the opposition party in making those changes. After House Democrats met behind closed doors Wednesday morning on Capitol Hill to formulate a health-care strategy, key members said they were focused on blocking any steps the administration might take to weaken the law while continuing to blame its shortcomings on Democrats.
"What we will do is lay out for the American people exactly what steps [Trump] can and probably will take to try to undermine the law, so they understand when he takes those actions . . . that he is the one taking away health-care coverage from millions of Americans," said Rep. Joseph Crowley, D-N.Y., chairman of the House Democratic Caucus.
The Washington Post's Carolyn Johnson contributed to this report.