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
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)
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)
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)
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
speaks at a panel discussion "Jump-Starting the Housing Market" at the 2009 Milken Institute Global Conference in Beverly Hills,California April 28, 2009. REUTERS/Fred Prouser (UNITED STATES BUSINESS)
Anthony Scaramucci, co-managing partner and founder of Skybridge Capital speaks at the opening of the annual Skybridge Alternatives Conference (SALT) in Las Vegas May 6, 2015. REUTERS/Rick Wilking
Newly elected Congressmen Lou Barletta (R-PA) (R) and Tim Scott (R-SC) (C) arrive on Capitol Hill in Washington, November 17, 2010. The new members of the upcoming 112th Congress are going through orientation. REUTERS/Jim Young (UNITED STATES - Tags: POLITICS)
Florida Attorney General Pam Bondi speaks at the Republican National Convention in Cleveland, Ohio, U.S. July 20, 2016. REUTERS/Mike Segar
Representative Marsha Blackburn (R-TN) speaks during the final day of the Republican National Convention in Cleveland, Ohio, U.S. July 21, 2016. REUTERS/Mike Segar
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
Discover More Like This
BACK TO SLIDE
"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
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)
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
Rudy Giuliani was also rumored to be among Trump's top picks for attorney general. REUTERS/Joshua Roberts
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)
Sam Brownback is also one of the several names being considered for Agriculture Secretary. REUTERS/Mike Segar
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
Rick Scott is considered to be a top contender for Health and Human Services Secretary. REUTERS/Joe Skipper/File Photo
Jeff Miller's name has been bounced around many times for the Veterans Affairs Secretary position. (Photo By Tom Williams/CQ Roll Call)
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)
John Bolton is yet another rumored pick for secretary of state.
(Photo by Andrew Harrer/Bloomberg via Getty Images)
Discover More Like This
BACK TO SLIDE
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."