The Republican Study Committee (RSC), which is comprised of conservative House lawmakers, on Tuesday released a framework to reform the U.S. health care system by eliminating parts of the Affordable Care Act (ACA) and providing states with more regulatory authority.

Cheat sheet: What you need to know about the ACA

RSC members have said the proposal is designed to be an alternative to so-called "Medicare-for-All" and other single-payer proposals being touted by Democrats.

Rep. Mike Johnson (R-La.) and Rep. Roger Marshall (R-Kan.), co-chairs of RSC, said the committee's plan could serve as a replacement for the ACA if a federal appeals court strikes down the law. According to The Hill, the proposal appears to revisit many of the concepts Republicans previously proposed to repeal and replace the ACA.

Johnson said he worked closely with the White House on the proposal, and it is intended to "complement" the Trump administration's health care efforts. According to the Washington Examiner, Republican lawmakers have said they intend to release a second part of the proposal at a later date. 

Proposal details

The proposal would undo a majority of the ACA's coverage regulations, according to The Hill. For example, the proposal would not require health plans to cover the ACA's "essential health benefits." Instead, the proposal would allow states to choose which essential health benefits health plans must cover. The proposal also would:

• Eliminate the ACA's ban on annual and lifetime limits on covered benefits;
• Eliminate the ACA's rules requiring insurers to cover certain preventive care services at no cost to patients;
• Eliminate the ACA's Medicaid expansions and reallocate funds from the expansions to establish a federal and state block-grant system for Medicaid funding;
• Eliminate the ACA's requirements regarding age-banding, community rating, dependent coverage, medical loss ratios, and single-risk pools; and
• Increase the ACA's cap on health savings accounts (HSAs) to $9,000 for individuals and $18,000 for families, allow individuals to use HSAs to cover individual health plan premiums, remove requirements that HSAs be linked to high-deductible health plans, and prohibit the use of HSAs to subsidize the cost of abortion care.

Under the proposal, the federal government would reallocate funding for the ACA's exchange plan subsidies to instead help states establish high-risk pools, called Guaranteed Coverage Pools. The high-risk pools would subsidize health care costs for enrollees with costly medical conditions through federal grants and state-enacted premium restrictions, similar to how most high-risk pools operated before the ACA's implementation. The high-risk pools would prohibit participating insurers from increasing costs for patients who develop medical conditions after they enrolled in a health plan.

The proposal would not require states to establish the high-risk pools, and it would give states flexibility in how they design the pools if they choose to do so. For example, states could establish high-risk pools that resemble so-called "invisible" high-risk pools, like the model Maine used before the ACA was implemented or reinsurance programs.

The proposal would provide U.S. residents who have pre-existing medical conditions with some of the protections currently in place under the ACA, and would offer states federal grants to help provide low-income individuals with access to health coverage. The federal government would fund the grants using money that otherwise would gone toward the ACA's Medicaid expansions and exchange premium subsidies.  

The proposal also would expand health care sharing ministries and association health plans.

Reaction

Conservative groups expressed support for the plan.

Jason Pye, vice president of legislative affairs for the conservative organization FreedomWorks, said, "From the large expansion of [HSAs] to the elimination of many provisions of current law that have made health insurance coverage so unaffordable, Americans across the country will benefit from the choice afforded to them by this plan."

The Heritage Foundation also expressed support for the proposal. Marie Fishpaw, director of domestic policy at the organization, said, "With health care a top concern for most Americans, it's imperative for Congress to return to health reform and offer Americans real relief from high health care costs and limited choices they face in the current system."

But Democrats are coming out against the proposal.

House Speaker Nancy Pelosi (D-Calif.) in tweet posted Tuesday wrote, "After 10 years of refusing to work with Democrats to #ProtectOurCare, the only plans offered by Republicans don't cover & protect preexisting conditions. They say their plan is an alternative to the Affordable Care Act but it's really just an alternative to health care, period" (Weixel/Brufke, The Hill, 10/22; Leonard/Morrison, Washington Examiner, 10/22; Olson, Fox News, 10/22; Cohen, Inside Health Policy, 10/22 [subscription required]).