The pledge by President-elect Donald Trump and congressional Republicans to "repeal and replace" the Affordable Care Act beginning early next year has dominated the national policy debate since Trump, and the GOP swept to victory in last week's election.
With potentially 20 million or more Americans threatened with the disruption or loss of their Obamacare insurance coverage in the coming years, Trump and GOP leaders are coming under mounting pressure to explain precisely how they would replace Obamacare once they pass legislation early next year to dismantle key elements of the program.
Related: Top 2016 issues: Health, Obamacare opinions, Medicare, abortion
Opponents and supporters of Planned Parenthood demonstrate Tuesday, July 28, 2015, in Philadelphia. Anti-abortion activists are calling for an end to government funding for the nonprofit reproductive services organization. (AP Photo/Matt Rourke)
Anti-abortion activists demonstrate near a Planned Parenthood clinic Tuesday, July 28, 2015, in Philadelphia. The protestors are calling for an end to government funding for the nonprofit reproductive services organization. (AP Photo/Matt Rourke)
Kathy Calver listens to a speaker as she and other anti-abortion activists rally on the steps of the Texas Capitol to condemn the use in medical research of tissue samples from aborted fetuses, Tuesday, July 28, 2015, in Austin, Texas. (AP Photo/Eric Gay)
Razor grass and pro-choice signs limit the view of patients entering the Jackson Women's Health Organization clinic in Jackson, Miss., Tuesday, June 30, 2015. Mississippi's only abortion clinic will likely remain open at least until the fall, because the U.S. Supreme Court is taking no action until then on a dispute over a state law that could close it. (AP Photo/Rogelio V. Solis)
MANHATTAN, NEW YORK CITY, UNITED STATES - 2015/08/22: Assembly of some 150 anti-abortion protesters behind barricade in front of Planned Parenthood. A coalition of anti-abortion protesters protested on Mott Street in Manhattan in front of Planned Parenthood. (Photo by Andy Katz/Pacific Press/LightRocket via Getty Images)
MANHATTAN, NEW YORK CITY, UNITED STATES - 2015/08/22: Protester with Baby Doe sign in front of Planned Parenthood. A coalition of anti-abortion protesters protested on Mott Street in Manhattan in front of Planned Parenthood. (Photo by Andy Katz/Pacific Press/LightRocket via Getty Images)
WASHINGTON, DC - JULY 28: Republican presidential candidate Dr. Ben Carson speaks at a anti-abortion rally opposing federal funding for Planned Parenthood in front of the U.S. Capitol July 28, 2015 in Washington, DC. Planned Parenthood faces mounting criticism amid the release of videos by a pro-life group and demands to vote in the Senate to stop funding. (Photo by Olivier Douliery/Getty Images)
WASHINGTON, DC - JULY 28: Republican presidential candidate, U.S. Sen. Ted Cruz (R-TX) speaks during a Anti-abortion rally opposing federal funding for Planned Parenthood in front of the U.S. Capitol July 28, 2015 in Washington, DC. Planned Parenthood faces mounting criticism amid the release of videos by a pro-life group and demands to vote in the Senate to stop funding. (Photo by Olivier Douliery/Getty Images)
UNITED STATES - JANUARY 22: Pro-choice protesters chant in front of the Supreme Court on Thursday, Jan. 22, 2015, the anniversary of the Roe v Wade abortion decision. (Photo By Bill Clark/CQ Roll Call)
Republican presidential candidate, Wisconsin Gov. Scott Walker, presents his plan to replace Obamacare, during a visit to Cass Screw Machine Products, Tuesday, Aug. 18, 2015, in Brooklyn Center, Minn. (AP Photo/Jim Mone)
UNITED STATES - FEBRUARY 5: Sen. Marco Rubio, R-Fla., testifies during the House Oversight and Government Reform Committee hearing on 'ObamaCare: Why the Need for an Insurance Company Bailout?' on Wednesday, Feb. 5, 2014. (Photo By Bill Clark/CQ Roll Call)
Sen. Chris Murphy, D-Conn., second from right, accompanied by Sen. Tammy Baldwin, D-Wisc., left, Sen. Sherrod Brown, D-Ohio, second from left, and Sen. Bob Casey, D-Pa., right, speaks at a press conference on the positive affects of the Affordable Care Act as the Senate convenes for a Sunday session on Capitol Hill in Washington, Sunday, July 26, 2015. On the Senate's agenda is an effort to repeal President Barack Obama's health care law. (AP Photo/Andrew Harnik)
President Barack Obama talks to a man in the audience as he takes questions at Taylor Stratton Elementary School in Nashville, Tenn., Wednesday, July 1, 2015, where he spoke about the Affordable Care Act. The president said he wants to refocus on improving health care quality, expanding access and rooting out waste now that the Supreme Court has upheld a key element of his health care law. (AP Photo/Carolyn Kaster)
Jessica Ellis, right, holds a sign that says "yay 4 ACA," as she and other supporters of the Affordable Care Act react with cheers as the opinion for health care is reported outside of the Supreme Court in Washington, Thursday June 25, 2015, in Washington. (AP Photo/Jacquelyn Martin)
Trent Seubert, left, holds a sign stating that 165,000 people would lose healthcare coverage, as the words "lose healthcare" are covered over with a "still covered" sticker outside the Supreme Court in Washington, Thursday, June 25, 2015, after the court decided that the without the Affordable Care Act (ACA) may provide nationwide tax subsidie. (AP Photo/Jacquelyn Martin)
FILE - In this Nov. 12, 2014 file photo, the HealthCare.gov website, where people can buy health insurance, is displayed on a laptop screen, in Portland, Ore. The Illinois Hospital Association in cash-strapped Illinois says the state might be able to set up a health insurance exchange at a lower cost by âleasingâ the federal governmentâs technology, an option that could appeal to as many as 34 states where subsides could be jeopardized by an unfavorable Supreme Court ruling. . (AP Photo/Don Ryan, File)
UNITED STATES - JUNE 25: Affordable Care Act supporters hold up signs outside the Supreme Court as they wait for the court's decision on Obamacare on Thursday, June 25, 2015. (Photo By Bill Clark/CQ Roll Call)
FILE-- In this Sept. 16, 2013 file photo, Gov. Rick Snyder, center, signs legislation at Oakwood Hospital in Dearborn, Mich. that will make more low-income adults eligible for Medicaid. One year after more low-income adults in Michigan became eligible for Medicaid under the federal health care law, enrollment is skyrocketing near 600,000, well above initial projections. (AP Photo/Carlos Osorio)
IMAGE DISTRIBUTED FOR AIDS HEALTHCARE FOUNDATION - Over 50 AIDS awareness advocates gather to protest in front of the Employment Development Department spearheaded by AIDS Healthcare Foundation (AHF) on Thursday, March 19, 2015, in Sacramento, Calif. The protest was over Cal/OSHAâs five-year delay in amending and tightening California workplace safety regulations regarding condom use in adult film production to better protect adult film workers. (Steve Yeater/AP Images for AIDS Healthcare Foundation) Â
University of Maryland medical student Sarah Britz, center, and others, rally outside the Supreme Court in Washington, Wednesday, March 4, 2015 in Washington, as the court was hearing arguments in King v. Burwell, a major test of President Barack Obama's health overhaul which, if successful, could halt health care premium subsidies in all the states where the federal government runs the insurance marketplaces. (AP Photo/Andrew Harnik)
In this photo taken Feb. 24, 2015, Kimberly Davis holds the medications she now takes to slow the progression of her multiple sclerosis, at her home in Jackson, Miss. The Supreme Court will hear arguments next week over whether millions of people covered by the nationâs health care law can legally continue to get financial help to pay for their insurance. If the court says no, millions of consumers across more than 30 states could lose federal subsidies for their premiums. (AP Photo/Rogelio V. Solis)
UNITED STATES - JUNE 25 - Supporters of the Affordable Care Act celebrate as the opinion for health care is reported outside of the Supreme Court in Washington,Thursday June 25, 2015. The Supreme Court on Thursday upheld the nationwide tax subsidies under President Barack Obama's health care overhaul, in a ruling that preserves health insurance for millions of Americans. (Photo By Al Drago/CQ Roll Call)
RICHMOND, CA - MARCH 31: Posters about Obamacare are posted on a window during a healthcare enrollment fair at the Bay Area Rescue Mission on March 31, 2014 in Richmond, California. SEIU-United Healthcare Workers West (SEIU-UHW) held the fair to help people sign up for free and low-cost health coverage through Medi-Cal or Covered California on the final day before the sign-up deadline. (Photo by Justin Sullivan/Getty Images)
However, practically overnight the Republicans have substantially raised the stakes in their drive to reform the government health care system and cut costs. House Budget Committee Chair Tom Price (R-GA) told reporters on Thursday that the House GOP will likely push next year for major changes and cuts in Medicare, the premier health care program for 57 million seniors that has been the bedrock of retirees' health coverage since the mid-1960s.
Price, who reportedly is being considered by Trump to head the Department of Health and Human Services, said that Republicans would likely move "within the first six to eight months" of Trump's administration to begin implementing their plan. Key elements include raising the age of eligibility from 65 to 67 and gradually privatizing the system with government-issued vouchers or "premium supports" to defray the cost of insurance policies purchased on the open market.
Trump repeatedly promised during the presidential campaign that he would not cut Social Security or Medicare to control government spending and address long-term deficit problems. "So, you've been paying into Social Security and Medicare...but we are not going to cut your Social Security, and we're not cutting your Medicare," Trump said at a rally in Iowa in December 2015.
However, privatization of Medicare has long been a central feature of House Speaker Paul Ryan's highly controversial budget proposals that enjoyed substantial GOP support in the House but never made it past the Senate. Now Ryan and other Republican House leaders believe that the election results are a mandate to push a bold agenda including Medicare reform – much to the dismay of advocates of the program.
"This is one case where there just seems to be a gross contradiction between something that Trump clearly stated and what the congressional Republicans are now talking quite openly about doing next year," said Paul N. Van de Water, a senior fellow at the liberal Center for Budget and Policy Priorities. "I didn't follow Trump's promises verbatim over the campaign, but everybody certainly seems to have picked up the notion that he promised not to cut Social Security and Medicare."
Related: Trump's transition team
Donald Trump's transition team
Donald Trump's transition team
U.S. President-elect Donald Trump and Chairman of the Republican National Committee Reince Priebus address supporters during his election night rally in Manhattan, New York, U.S., November 9, 2016. REUTERS/Mike Segar
Republican vice presidential nominee Mike Pence attends a campaign rally in Manchester, New Hampshire, U.S. November 7, 2016. REUTERS/Carlo Allegri
Campaign CEO Stephen Bannon departs the offices of Republican president-elect Donald Trump at Trump Tower in New York, New York, U.S. November 11, 2016. REUTERS/Carlo Allegri
U.S. Republican presidential candidate Governor Chris Christie speaks to supporters in West Des Moines, Iowa, U.S. January 31, 2016. REUTERS/Brian C. Frank/File Photo
Former candidate Ben Carson arrives to attend the third and final 2016 presidential campaign debate between Republican U.S. presidential nominee Donald Trump and Democratic nominee Hillary Clinton at UNLV in Las Vegas, Nevada, U.S., October 19, 2016. REUTERS/Mike Blake
Former New York Mayor Rudy Giuliani leaves the offices of Republican President-elect Donald Trump at Trump Tower in New York, New York, U.S., November 11, 2016. REUTERS/Carlo Allegri
Former House Speaker Newt Gingrich speaks at the Republican National Convention in Cleveland, Ohio, U.S. July 20, 2016. REUTERS/Mark Kauzlarich
Defense Intelligence Agency director U.S. Army Lt. General Michael Flynn testifies before the House Intelligence Committee on "Worldwide Threats" in Washington February 4, 2014. REUTERS/Gary Cameron/File photo TPX IMAGES OF THE DAY
U.S. Senator Jeff Sessions (R-Al) speaks at the Republican National Convention in Cleveland, Ohio, U.S. July 18, 2016. REUTERS/Mike Segar
Republican President-elect Donald Trump's daughter Ivanka Trump arrives at Trump Tower in New York, New York, U.S., November 11, 2016. REUTERS/Carlo Allegri
Son of Republican President-elect Donald Trump Eric Trump gives the thumbs up as he arrives at Trump Tower in New York, New York, U.S., November 11, 2016. REUTERS/Carlo Allegri
Donald Trump Jr. sits between his wife Vanessa (L) and his brother Eric Trump (R) during the third and final debate between Republican U.S. presidential nominee Donald Trump and Democratic nominee Hillary Clinton at UNLV in Las Vegas, Nevada, U.S., October 19, 2016. REUTERS/Rick Wilking
Jared Kushner (L) and Stephen Bannon stand by as Republican presidential nominee Donald Trump holds a campaign rally in Canton, Ohio, U.S., September 14, 2016. REUTERS/Mike Segar
PayPal co-founder and Facebook board member Peter Thiel delivers his speech on the U.S. presidential election at the National Press Club in Washington, U.S., October 31, 2016. REUTERS/Gary Cameron
Steven Mnuchin, Chairman and Co-CEO of Dune Capital Management LP and Chairman and CEO of OneWest Bank Group LLC
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U.S. Representative Chris Collins (R-NY) flashes a thumbs-up before delivering his nomination speech at the Republican National Convention in Cleveland, Ohio, U.S. July 19, 2016. REUTERS/Jim Young
U.S. Representative Devin Nunes (R-CA) talks to reporters as he walks from the offices of House Speaker John Boehner (R-OH) (not pictured) at the U.S. Capitol in Washington, October 15, 2013. Republicans in the House of Representatives failed to reach internal consensus on Tuesday on how to break an impasse on the federal budget that could soon result in an economically damaging default on the country's debt. REUTERS/Jonathan Ernst (UNITED STATES - Tags: POLITICS BUSINESS MEDIA)
Campaign Communications Director Hope Hicks departs the offices of Republican president-elect Donald Trump at Trump Tower in New York, New York, U.S. November 11, 2016. REUTERS/Carlo Allegri
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"It's hard to see how one could square that with either premium support for example or certainly raising the Medicare age," he added in an interview Friday. "Both of those are either reducing benefits or requiring people to pay more for the same benefits, which is essentially the same thing."
For years dating back to the administration of President George W. Bush, Republicans have been advancing proposals for replacing traditional Medicare with some private system, but those proposals have never gotten very far. The latest iteration of that plan – to preserve traditional Medicare for those currently in the system but to pressure younger Americans to gradually shift to a voucher plan – was included in a major health care policy paper Ryan released June 22 called "A Better Way– Our Vision for a Confident America."
"Medicare . . . by many measures has served seniors successfully since the1960s by providing access to health care for millions and contributing to longer life expectancies," Ryan wrote. "Despite these successes, the program faces notable challenges, including a complex financial structure and projected spending growth that make the program unsustainable for the long term."
"If we act now, this can mean that traditional Medicare will continue for those currently on the program or near Medicare eligibility," he added.
Ryan said last week that Medicare would be up for review in the new Congress, although he did not signal a precise timetable or how he hoped to orchestrate passage of legislation that is certain to be met with a firestorm of opposition from AARP and other seniors' advocacy groups, veterans and liberal Democrats.
Related: Trump's rumored picks for the Trump administration
Donald Trump's rumored picks for his administration
Donald Trump's rumored picks for his administration
Sarah Palin is rumored to be among Trump's picks for Interior Secretary. (AP Photo/Evan Vucci)
Trump named Jeff Sessions his pick for U.S. attorney general. (MANDEL NGAN/AFP/Getty Images)
Trump named Retired Lt. Gen. Michael Flynn his pick for National Security Adviser. (Photo by Drew Angerer/Getty Images)
Trump named Rep. Mike Pompeo, R-Kan., as his preferred pick for CIA director. (AP Photo/Jacquelyn Martin, File)
Newt Gingrich is rumored to be among Trump's top picks for secretary of state. REUTERS/Eduardo Munoz
Mitt Romney has reportedly been in discussions for secretary of state.
Steven Mnuchin is rumored to be Trump's top pick for Treasury Secretary. (KENA BETANCUR/AFP/Getty Images)
Bob Corker is also rumored to be among Trump's picks for secretary of state. REUTERS/Mike Theiler
Stephen Hadley is rumored to be in the running for secretary of defense. REUTERS/Larry Downing
Jim Talent is rumored to also be in the running for secretary of defense. REUTERS/Tim Parker
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Forrest Lucas is rumored to be Trump's top pick for Interior Secretary. ( Amanda Edwards/WireImage)
Robert Grady is also being eyed for the Interior Secretary position. REUTERS/Fred Prouser
Donald Trump Jr. is also said to have interest in the Interior Secretary position. (REUTERS/Mike Segar)
Controversial pick Sid Miller is one of the many being considered for Agriculture Secretary. (AP Photo/Eric Gay, File)
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Billionaire Wilbur Ross is a rumored choice for Commerce Secretary. FINANCE-WLROSS/ REUTERS/Tim Chong
Daniel Dimicco, a Trump Trade Advisor is also on the possible list for Commerce Secretary. REUTERS/Chris Keane
Victoria Lipnic (left) is being considered for Labor Secretary.(AP Photo/Wade Payne)
Rick Scott is considered to be a top contender for Health and Human Services Secretary. REUTERS/Joe Skipper/File Photo
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Harold Hamm is considered to be the top contender for Energy Secretary. (AP PhotoKevin Cederstrom)
Jeff Miller's name has been bounced around many times for the Veterans Affairs Secretary position. (Photo By Tom Williams/CQ Roll Call)
David Clarke is rumored to be among Trump's top picks for Homeland Security Secretary. (AP Photo/J. Scott Applewhite)
Myron Bell who has been a part of Trump's transition team is rumored to be the top pick for Environmental Protection Agency Administrator position.
Photo Credit: Twitter/oliverwasow
Representative Tom Price of Georgia is being considered for the position of secretary of health and human services.
(Photo by Andrew Harrer/Bloomberg via Getty Images)
Ivana Trump, the president-elect's ex-wife, has said she wants Trump to name her as ambassador to the Czech Republic.
(Photo by Michael Zorn/Invision/AP)
John Bolton is yet another rumored pick for secretary of state.
(Photo by Andrew Harrer/Bloomberg via Getty Images)
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House and Senate GOP leaders intend to use an obscure budget parliamentary maneuver called reconciliation to push legislation through in January to repeal Obamacare by a simple majority, without having to muster a 60-vote supermajority to overcome a Democratic filibuster.
House GOP leaders will likely use reconciliation to push through a second budget resolution for fiscal 2018 that includes their Medicare reform package, according to Price. When asked by a reporter for the publication TPM about timing for changes to Medicare, Price replied yesterday: "I think that is probably in the second phase of reconciliation, which would have to be in the FY 18 budget resolution in the first six to eight months."
Tampering with Medicare is politically risky at best. The federally funded health care program covers much of the cost of hospital care, physician visits and drugs for those 65 and older. Medicare benefit payments totaled $632 billion in 2015 and accounted for 15 percent of the federal budget. Medicare is funded primarily with general revenues (42 percent), payroll taxes (37 percent), and beneficiary premiums (13 percent).
Medicare spending growth has slowed in recent years, according to an analysis by the Kaiser Family Foundation. While costs are expected to continue to grow more slowly in the future compared to historical trends, "there are signs that spending growth could increase at a faster rate than in recent years," in part because of rising prescription drug spending, growing enrollment in Medicare, and increases in provider payments.
However, Ryan and other deficit hawks have long argued that Medicare's spending trajectory is not sustainable as the population ages and more and more baby boomers seek coverage. He cites a Congressional Budget Office estimate that the Part A Hospital Insurance trust fund will be insolvent in 2026, four years earlier than previously projected.
The Republicans' solution, in part, is to raise the Medicare eligibility age beginning in 2020 and moving Medicare toward a "premium support" model. Instead of continuing with Medicare's current guarantee of paying for a certain level of coverage – roughly 80 percent or more for a hospital stay—a premium support or "voucher" plan would provide seniors with a fixed sum to purchase health care coverage on the private insurance market, according to an analysis by the Center for Budget and Policy Priorities.
The size of the premium support would likely vary by region, to account for regional differences in health care costs, according to the analysis. Moreover, it would provide enough of a subsidy to purchase a modest insurance plan, at least in the beginning.
Seniors could choose from a menu of private health care plans offering a wide range of coverage, and the government would pay the Medicare premium supports directly to the plan to subsidize the cost. Seniors would have to pick up the rest of the cost.
Ryan said the program would operate like the Federal Employees Health Benefits (FEHB) program, "where plans compete for individuals' choice based upon premium amount, and a certain percentage is offset by the government to lower the cost of the coverage."
Van de Water, who wrote the CBPP analysis, said Ryan's latest proposal leaves many questions unanswered, including whether it would address mounting co-payments and other out-of-pocket costs, or whether the vouchers would be tied to inflation to keep up with rising health care costs.
"I don't think we have any idea under the current plan how fast the vouchers grow," he said.
That is an important question because it goes to the fears of many critics that the voucher plan would fall far short of what seniors would need to purchase adequate coverage, and that it would shift more and more health care costs away from the government and to a rapidly aging population.
What's more, as the government makes it more expensive to remain in traditional Medicare, younger and healthier seniors would likely gravitate to cheaper, individual health care plans while older and sicker seniors would continue to cling to traditional Medicare. That would put more and more financial pressure on the government program, further undermining its financial stability.
"That's the general consensus on this," Van de Water said. "Premium support would be a threat to traditional Medicare."