Republican ACA Alternatives Thus Far

ACA Replacement
Photo credited to Caleb Smith, Office of the Speaker of the House

With both the Presidency and Congress firmly in control of the Republican Party, post-election expectations are high on the inevitable undoing of the the Affordable Care Act (a.k.a Obamacare). Republican legislatures have a tough challenge ahead as they seek a viable alternative to the deeply rooted ACA, with many lawmakers facing fiery constituents concerned about the future of healthcare.

On March 6th, Speaker Paul Ryan unveiled “The American Healthcare Act” as the latest effort to undue the ACA, which has since been met with mixed reviews as some Republicans view the bill as too left-leaning. Prior to this proposal, key Republican leaders had already put forth several proposals to replace the ACA, including current Secretary of Health and Human Service (HHS) Tom Price, Senator Bill Cassidy, and Senator Rand Paul. Here is an overview of what each plan proposes, and an infographic to help simplify each:

ACA Replacement Comparison

Speaker Paul Ryan’s (American Healthcare Act)

  • Repeal ACA mandates (2016), standards for health plan actuarial values (2020), and, premium and cost sharing subsidies (2020).
  • Modify ACA premium tax credits for 2018-2019
  • Retain private market rules
  • Retain health insurance marketplaces, annual Open Enrollment periods (OE)
  • Impose late enrollment penalty for people who don’t stay continuously covered
  • Establish State Innovation Grants and Stability Program
  • Repeal funding for Prevention and Public Health Fund
  • Encourage use of Health Savings Accounts
  • Eliminate enhanced FMAP for Medicaid expansion as of January 1, 2020 except for those enrolled as of December 31, 2019 who do not have a break in eligibility of more than 1 month
  • Convert federal Medicaid funding to a per capita allotment and limit growth beginning in 2020 using 2016 as a base year
  • No change to Medicare benefit enhancements or provider/Medicare Advantage plan payment savings
  • Repeal Medicare HI tax increase and other ACA revenue provisions
  • Prohibit federal Medicaid funding for Planned Parenthood clinics

HHS Secretary Tom Price (Empowering Patients First Act)

  • Repeal ACA entirely
  • Provide refundable tax credits
  • Pre-existing condition exclusions
  • Implement state high-risk pools
  • Permit sale of insurance across state lines
  • Repeal Medicaid expansion
  • Repeal Medicare enhancements
  • Encourage use of Health Savings Accounts (HSA’s)
  • Cap the tax exclusion for employer-provided health benefits
  • Permit enrollees to opt out of coverage under public programs and employer sponsored group health plans

Senator Bill Cassidy (Patient Freedom Act)

  • State option to continue or discontinue implementation of Title I of ACA
  • Retain some private market rules in all states
  • Retain option for all states to expand Medicaid
  • In Patient-Grant Electing states provide federal monthly deposits to new health savings accounts
  • In Patient-Grant Electing states require insurers to offer portability protections
  • No changes to Medicare

Senator Rand Paul (Obamacare Replacement Act)

  • Repeal most private market rules
  • Restore pre-ACA portability protections under HIPAA
  • Retain ACA premium and cost sharing subsidies for non-group plans sold through the Marketplace
  • Encourage use of Health Savings Permit sale of insurance across state lines
  • Retain Medicaid expansion and increase state flexibility to obtain waivers
  • No changes to Medicare

A more descriptive side by side comparison of the ACA replacement proposals can be found on the Kaiser Family Foundation website.