The president has won praisefrom both conservatives and liberals for such things as hisproposals to require hospitals to post their actual, negotiatedprices, and some strategies to lower drug prices. (Photo: DougMills/Pool via Bloomberg)

While many Capitol Hill Republicans want to avoid a repeat ofthe Affordable Care Act repeal debate, President Donald Trump keepspromising a health plan that will be "phenomenal"and make the GOP "theparty of health care."

Last month, Medicare chief Seema Verma said, "We're actively engaged in conversations" on what to do.Earlier in August, Trump adviser Kellyanne Conway indicated anannouncement might come this month.

Behind the pronouncements lies a conundrum: whether to stray beyond efforts underway toimprove the nation's health care system — loosening insuranceregulations, talking about drug prices, expanding tax-free healthsavings accounts — to develop an overarching plan.

For the White House, it's a fraught decision.

A comprehensive plan could be a lightning rod for opponents.Conversely, not having a plan for replacing some of the mostpopular parts of Obamacare — such as its coverage protections forpeople with preexisting medical conditions — could leave the GOPflat-footed if an administration-supported lawsuit before the 5thCircuit Court of Appeals invalidates the sweeping health law.

"This is a real conundrum. There is a risk with action orinaction," said Dean Rosen, a Washington, D.C., health policyconsultant who often advises Republicans.

No matter how the 5th Circuit rules, its decision, which couldcome soon, is likely to be stayed while the issue heads to theSupreme Court. Such a delay would give the administration time toflesh out a proposal if the appeals judges throw out the ACA, butit would also ensure that a health care debate is front and centerduring the presidential campaign.

Right now, polls show the public is focused on health costs,said professor Robert Blendon, who directs the Harvard OpinionResearch Program, which studies public knowledge of health care andpolicy issues. Consumers are concerned about what they pay at thepharmacy counter or the sum of their insurance premiums anddeductibles.

"Most voters are not interested in another debate on a newhealth plan," he said.

But if the 5th Circuit upholds a Texas ruling overturning theentire ACA, "that changes the entire framework," said Blendon. "Theadministration could not just say, 'Oh, we'll have somethinggreat.' They would have to have something outlined."

Supporters and critics say likely elements are already in plainsight, both in executive actions and proposals in the president'sbudget as well as a little-noticed white paper released late lastyear.

The president has won praise from both conservatives andliberals for such things as his proposals to require hospitals topost their actual, negotiated prices, and some strategies to lowerdrug prices. But legal battles within the health industry couldthwart such initiatives.

On these topics, "a lot of what they've proposed has been prettysmart," said Shawn Gremminger, senior director of federal relationsat the liberal Families USA advocacy group.

Still, Gremminger points to other administration actions —loosening rules on health insurers to allow sales of what criticscall "junk" insurance because they don't have all the consumerprotections of ACA policies, or promoting work requirements forMedicaid recipients — as strong hints to what might be in anyeventual election-related plan.

"I think what we'll see is a lot of that same sort of stuff,warmed over and put into a new package," Gremminger said. "We fullyexpect it will include a lot of really terrible ideas."

For other policy clues, some advisers, like Brian Blase, aformer special assistant to the president at the National EconomicCouncil, said look no further than that little-noticed 2018interagency report.

The 114-page document includes more than two dozen recommendations thatbroadly focus on loosening federal and state regulations, limitinghospital and insurer market power and prompting patients to be moreprice-conscious shoppers.

Many are long-standing Republican free-market favorites, such asincreasing the use of health savings accounts, which allowconsumers to set aside money, tax-free, to cover medical expenses.Other ideas are not typically associated with the GOP, such asincreased federal scrutiny of hospital and insurer mergers, whichhave driven up prices.

The paper also calls for less restrictive rules for the MedicareAdvantage plans that offer an alternative to the traditionalfee-for-service Medicare. It would allow the advantage program tohave smaller networks of doctors and hospitals — presumably onesthat agreed to charge less.

"The administration knows where it is going on health care,"said Blase.

If the court strikes down the ACA, he expects the administrationto release a plan supporting "generously funded state-based,high-risk pools."

Such pools existed in most states before the ACA. They helpedprovide coverage for people with preexisting conditions who weredenied policies by insurers. But the pools were expensive, so theyoften were underfunded, capped members' benefits and yielded longwaiting lists.

Some think the white paper is not so much a plan as a"combination of policy ideas and political statements," said JoeAntos at the conservative-leaning American EnterpriseInstitute.

Still, he doubts the GOP needs a comprehensive health proposal.Republicans are more likely to gain politically by merely attackingthe Democrats' ideas, he said, especially if the Democratic nomineebacks proposals for a fully government-funded health care system,such as the "Medicare for All" plans some candidates support.

Republicans will "have their own one-liners, saying they arededicated to protecting people with preexisting conditions. Thatmight be enough for a lot of people," Antos said.

Politically, it's risky. While many voters don't understand allthat the ACA does, some of its rules enjoy broad support. That'sparticularly true of the protections for people with medicalproblems — insurers are barred from rejecting them for coverage orcharging them more than people without such conditions.

The Republican effort to repeal the law galvanized activistsduring the 2018 midterm elections and is credited with boostingDemocrats to victory in many House districts.

Analysts on both sides expect concerns about health costs andthe ACA to play a large role again in 2020.

For Republicans, "the risk of doing nothing potentially leavesno port in a storm if the ACA is overturned legally," said Rosen."But a more limited version, which is what most Republicans arefor, is likely to be met with the same concerns. No matter what thepresident says, it won't be enough for the Democrats."

Opinion poll analyst Blendon said there is an additionalunknown: which Democrat will win the nomination — and what type ofcoverage he or she will back.

Even as the GOP is split on how to address health care concerns,so too are the Democrats.

"If they are reading the same polling data as I am, they wouldhave serious proposals for lowering drug and hospital costs, butnot offer a national health plan," said Blendon.

The Democrats' most progressive wing, led by Sens. BernieSanders of Vermont and Elizabeth Warren of Massachusetts, wantsMedicare for All, which would essentially eliminate private andjob-based coverage. Recent polls have shown voters are not keen to lose private insurance.

The party's center, led by former Vice President Joe Biden,wants to keep the ACA but apply "fixes" to make insurance purchasedby individuals more affordable.

"If the Democratic nominee is running on keeping the ACA, theRepublican will have to have an alternative," said Blendon. But, ifthe nominee supports Medicare for All, he predicts simply a GOP"anti-campaign" targeting the Democrat's idea as unworkable,socialist or a danger to Medicare.

Kaiser Health News isa nonprofit news service covering health issues. It is aneditorially independent program of the Kaiser Family Foundation,which is not affiliated with Kaiser Permanente.

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