House Republicans are debating a plan to replace the Affordable Care Act that would give consumers tax credits to buy insurance, cut back on Medicaid and allow people to save their own money to pay for health care costs.

The outline plan is likely to take away some of the financial help low-income families get through Obamacare subsidies, and also result in fewer people being covered under the Medicaid health care program for the poor.

“In general this is going to result in fewer people covered nationwide,” says Caroline Pearson, a senior vice president at Avalere, a health care consulting group.

Republican leaders distributed the skeleton proposal at a meeting of the House Republican Conference in the Capitol on Thursday. Lawmakers now have an outline to bring with them to their districts for the Presidents Day holiday weekend, where they may face constituents with questions about what is going to happen to their health care. The plan is based on one outlined last summer by House Speaker Paul Ryan.

Rep. Bill Huizenga, R-Mich., called the 18-page outline “guideposts and a road map.”

“We know the direction we want to go and sort of the destination,” Huizenga said outside the meeting.

Lawmakers who attended the meeting said the plan is to repeal the Affordable Care Act with a bill similar to one that passed in 2015 but was vetoed by then-President Barack Obama. That proposal would have repealed all the taxes and subsidies associated with the health care law and would have killed the mandate for individuals to buy health insurance by getting rid of the tax penalty used to enforce it.

This Congress could either first pass a repeal bill and then a replacement bill, or include replacement elements in the repeal.

The meeting Thursday centered on “principles and goals on where we’re going in patient-centered care,” said House Ways and Means Committee Chairman Kevin Brady, R-La., after the meeting.

“We’re talking about repealing, replacing and starting to return control of health care and restoring the free market,” he said.

Most of the plan is silent on how much money lawmakers want to put behind their proposals, so it’s impossible to know exactly how generous the plan is and how many people it would cover.

The elements of the plan include replacing the subsidies that help people buy insurance through Obamacare exchanges with fixed tax credits to buy coverage on the open market.

The major difference between the two is that the Obamacare subsidies increase as premiums rise so that consumers are responsible for the same premium amount, which is tied to their income. The tax credits proposed by Ryan are not tied to income but rise as a person ages and insurance rates increase.

“The important thing on the tax credits is that they’re not income adjusted and we don’t know how big they are,” Pearson says.

She says it’s unlikely they’ll be as generous as the Obamacare subsidies.

“This likely means that low-income people will have difficulty affording individual insurance,” she says.

The outline distributed by Republicans repeatedly mentions that people will be able to buy so-called catastrophic coverage, which has limited day-to-day benefits but protects people when they have a serious illness or accident that requires a lot of health care.

The plan also calls for expanding health savings accounts, which allow people to save their own money tax-free to pay for health care costs. It calls for the limits on HSA savings to rise from $6,750 per family to $13,100.

HSAs are a favorite among conservatives because they encourage people to save and plan for their health spending and to shop around for price.

Democrats have criticized the focus on HSAs because they only help people who have extra money to put away and give a bigger tax cut to people with higher incomes.

The Republicans’ plan also calls for a major restructuring of the Medicaid health care program for the poor. It would repeal the Medicaid expansion that most states adopted under the Affordable Care Act, which allowed able-bodied people with incomes just above the poverty line to become eligible for Medicaid coverage.

And it would cap how much the federal government spends per person per year. Right now, Medicaid pays all health care costs for those who are eligible.

“This is a potentially significant incentive for states to get serious about efficiency,” says Paul Howard, director of health policy at the Manhattan Institute, a conservative think tank.

Howard says states currently have an incentive to increase their spending on Medicaid, because it boosts the amount of federal money they get.

Ryan’s plan would make Medicaid either a block grant program, where states receive a fixed amount of money, or it would be a per capita benefit, where the federal government would give the states a set amount for each beneficiary.

States could still offer Medicaid to those who became eligible under expansion, but the states’ share of the costs would be higher than it is under the Affordable Care Act, likely making it too expensive for many states to do so.

Finally, the Republican plan would offer states pools of cash to come up with ways to expand insurance access to more people.

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President Trump has promised to repeal and replace the Affordable Care Act without taking insurance away from the millions of people who gained coverage under the law.

On Wednesday his Department of Health and Human Services made its first substantive proposals to change the marketplaces for individual coverage, commonly known as Obamacare.

The proposed rules aim to keep insurers in the market during a transition to a new system. One way is to tighten up when people can sign up for coverage.

Insurers like Aetna. The company’s CEO, Mark Bertolini, said Wednesday that Obamacare is failing.

“It’s in a death spiral,” he said at a conference sponsored by The Wall Street Journal. “And in the first look at this quarter it’s not going to get any better. It’s getting worse.”

Bertolini hinted that Aetna may follow insurance giant Humana, which said Tuesday it was dropping out of the ACA exchanges altogether because not enough healthy people are buying insurance.

HHS’s proposed changes are designed to make the individual health care market less vulnerable to gaming by consumers. Insurance companies have complained that many people delay signing up until they’re sick and then drop coverage after getting care.

The administration’s proposals include cutting the annual open enrollment period to about six weeks instead of three months — to reduce the number of people who buy a policy because they find out about a health issue during that time.

HHS will also require people who want to sign up for coverage during so-called special enrollment periods to first prove they qualify because of a life change like losing a job or getting divorced.

“The overall effect of many of the policies here would actually, over time, I think, actually shrink enrollment, not grow enrollment,” says Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.

The rules would make it harder to enroll, and adding more paperwork will just turn off more people, she says, citing research into Medicaid and other public benefit programs.

And the people who leave are likely to be the healthier ones, making the situation even worse for insurance companies. “Your healthy people are the ones who are going to be more likely to say, ‘Oh, this is too much of a pain in the neck. I’m not going to go through with this,’ ” Corlette says

Still, Caroline Pearson, senior vice president at consulting firm Avalere, says some change is needed. “The special enrollment periods are a real problem in the market,” she says.

Her research shows that people who buy insurance during special enrollment periods incur a disproportionate share of money spent on health care.

The HHS proposal also allows insurers to increase deductibles and copayments, by loosening the standards of coverage. Right now plans are rated in terms of what proportion of the costs a customer pays. The new rules would widen the band by 2 percentage points, so that a plan that’s marketed as covering 60 percent of health costs could actually pay for as little as 56 percent of those.

The proposal also says insurance companies can demand consumers pay off any missed premiums before they get a new policy.

Today, a consumer can enroll in a plan, pay for just one month and then continue coverage for 90 days before getting cut off. The following year, the insurance company has to write a new policy even if the person hasn’t paid for those three months.

“In total, I think that the rule is helpful for insurers but probably not enough to change plans’ minds in how to approach the exchange markets,” Pearson says. “Plans that were going to leave the market will probably still leave the market and plans that were inclined to stay in will probably stay in, albeit a little happier.”

Humana is, therefore, unlikely to rethink its decision because of these changes.

As HHS tried to stabilize Obamacare while Congress debates its ultimate fate, the IRS is relaxing its plans to enforce the ACA’s tax penalty.

The agency had planned to reject tax returns of people who didn’t say whether they had health insurance during the tax year. But the IRS changed that policy in response to Trump’s executive order directing all federal agencies to ease the burden of the health care law.

Taxpayers may still owe the penalty if they don’t have coverage, however.

“Legislative provisions of the ACA law are still in force until changed by Congress, and taxpayers remain required to follow the law and pay what they may owe,” the IRS said in an emailed statement.

Pearson at Avalere says the combined actions by HHS and the IRS could lead healthy people to drop their insurance coverage.

“In total, I actually think the exchange market is going to shrink in size, dramatically, as a result of both the rule and the IRS move.”

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A version of this story was originally published by member station WAMU.

With the GOP fully in control of the federal government for the first time since 2006, Congressional Republicans are taking their first steps to assert their power over the District of Columbia’s local government.

After an impassioned debate, the House Oversight and Government Reform Committee voted Monday evening to block a D.C. law giving District physicians the right to prescribe lethal medication to terminally ill patients who have less than six months to live.

Committee chair Jason Chaffetz and other Republican conservatives have argued that the D.C. law should be nullified because it runs counter to ethical prohibitions against suicide. Most of the Republicans on the committee framed their opposition as a “pro-life” stance, with a number expressing concerns that the D.C. law could leave vulnerable dying patients at the mercy of physicians and relatives eager to hasten their exit.

“I worry that assisted suicide will create a marketplace for death,” Chaffetz said.

Rep. Darrell Issa R-Calif., who represents one of six states that already have enacted legislation similar to D.C.’s right-to-die bill, was the only Republican to vote against the measure. Issa argued that given Congress’ failure to stop such legislation nationally, he didn’t think interference in D.C. affairs was justified.

In a statement after the committee vote, Mayor Bowser called it “a signal to DC residents that Congress has zero respect or concern for their will or the will of their elected officials.”

Though the District gained an elected mayor and legislature in 1973, Congress retained broad authority over the city. That included the right to disapprove of bills — or, in simpler words, block bills passed by the D.C. Council from taking effect. But that right has been used sparingly: Congress has only formally blocked three D.C. bills over the last 45 years.

The panel voted 22-14 in favor of sending to the House floor the bill to the House floor. However that may be as far as it goes.

Unless conservative Republican backers of the manage to get the committee-passed “resolution of disapproval” through the House and Senate and signed by President Donald Trump by the end of the week — an exceedingly uphill battle given the normal pace of Congress — the law appears likely to take effect as passed by D.C. Council and signed into law by Mayor Muriel Bowser.

The bill becomes law if it is not blocked within 30 legislative working days of being sent Congress. By the D.C. City Council’s calculations, time is up for opponents of the Death With Dignity bill on or about Saturday.

That leaves an almost impossibly narrow window for floor votes in the House and Senate. Moreover, it is not even certain that Trump would sign a disapproval resolution. White House press secretary Sean Spicer refused to say what the president might do when asked about the Death With Dignity law at a press briefing last week.

The audience at the committee meeting, which lasted until past 7:30, included activists in the right-to-die movement, including at least one who considers herself a potential beneficiary: Mary Klein, a 69-year-old D.C. resident who is dying of cancer. In an earlier interview with WAMU, Klein described the measure’s passage, by an 11-2 D.C. Council vote in November, as “a great relief.” Dan Diaz, the widower of Brittany Maynard, a young woman who wrote about her decision to end her life after a long battle with brain cancer, also turned up “to support D.C.,” he said.

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The confirmation of Tom Price, the orthopedic surgeon-turned-Georgia congressman, as secretary of Health and Human Services on Friday represents the latest victory in the ascendancy of a little-known but powerful group of conservative physicians in Congress — the GOP Doctors Caucus.

During the Obama administration, the caucus regularly sought to overturn the Affordable Care Act, and it’s now expected to play a major role determining the Trump administration’s plans for replacement.

Robert Doherty, a lobbyist for the American College of Physicians, the professional organization for internal medicine doctors, says the GOP Doctors Caucus has gained importance with Republicans’ rise to power. “As political circumstances have changed, they have grown more essential,” Doherty says.

“They will have considerable influence over the discussion on repeal and replace legislation,” he says.

Price’s supporters have touted his medical degree as an important credential for his new position, but Price and the caucus members are hardly representative of America’s physicians in 2017.

The “trust us, we’re doctors” refrain of the caucus obscures its conservative agenda, critics say.

“Their views are driven more by political affiliation,” says Mona Mangat, an allergist-immunologist and chair of Doctors for America, a 16,000-member organization that favors the current health law. “It doesn’t make me feel great. Doctors outside of Congress do not support their views.”

For example, while the American College of Obstetrics and Gynecology has worked to protect access to abortion, the three obstetrician-gynecologists in the 16-member House caucus are anti-abortion and oppose the ACA provision that provides prescription contraception without copays.

While a third of the U.S. medical profession is now female, 15 of the 16 members of the GOP caucus are male, and only eight of them are doctors.

The other eight members are from other health professions, including a registered nurse, a pharmacist and a dentist. The nurse, Rep. Diane Black of Tennessee, is the only woman.

On the Senate side, there are three physicians, all of them Republican and male: Sen. John Barrasso, an orthopedic surgeon from Wyoming; Sen. Bill Cassidy, a gastroenterologist from Louisiana; and Sen. Rand Paul, an ophthalmologist from Kentucky.

While 52 percent of American physicians today identify as Democrats, just two out of the 14 doctors in Congress are Democrats, Reps. Ami Bera and Raul Ruiz, both of California.

About 55 percent of physicians say they voted for Hillary Clinton and only 26 percent voted for Donald Trump, according to a survey by Medscape in December.

Meanwhile, national surveys show doctors are almost evenly split on support for the health law, mirroring the general public. And a survey published in the New England Journal of Medicine in January found almost half of primary care doctors liked the law, while only 15 percent wanted it repealed.

Rep. Michael Burgess, R-Texas, a caucus member first elected in 2003, is one of the longest serving doctors in Congress. He says the anti-Obamacare Republican physicians do represent the views of the profession.

“Doctors tend to be fairly conservative and are fairly tight with their dollars, and that the vast proportion of doctors in Congress [are] Republican is not an accident,” he says.

Price’s ascendency is in some ways also a triumph for the American Medical Association, which has long sought to beef up its influence over national health policy. Less than 25 percent of practicing physicians are in the AMA, the organization says.

Price is an alumnus of a boot camp the AMA runs in Washington each winter for physicians contemplating a run for office. Price is one of four members of the caucus who went through the candidate school. In December, the AMA immediately endorsed the Price nomination, a move that led thousands of doctors who feared Price would overturn the health law to sign protest petitions.

Even without Price, Congress will have several GOP physicians in leadership spots in both the House and Senate.

Those include Rep. Phil Roe of Tennessee, the caucus co-chair, who also chairs the House Veterans Affairs Committee, and Burgess, who chairs the House Energy and Commerce subcommittee on health. Sen. Cassidy sits on both the Finance and the Health, Education, Labor and Pension Committees. Sen. Barrasso chairs the Senate Republican Policy Committee.

Roe acknowledges that his caucus will have newfound influence. Among his goals in molding an ACA replacement are to kill the requirement that most people buy health insurance (called the individual mandate) as well as to kill the requirement that 10 essential benefits, such as maternity and mental health care, must be in each health plan.

He says the caucus will probably not introduce its own bill, but rather evaluate and support other bills. The caucus could be a kingmaker in that role. “If we came out publicly and said we cannot support this bill, it fails,” Roe says.

The GOP Doctors Caucus has played a prominent role in health matters before.

For example, in 2015, when former House Speaker John Boehner needed help to permanently repeal a Medicare payment formula that threatened physicians with double-digit annual fee cuts, he turned to the GOP Doctors Caucus. It got behind a system to pay doctors based on performance — the so-called “doc fix.”

“When the speaker had a unified doctors’ agreement in his coat pocket, he could go to Minority Leader Nancy Pelosi and show that, and that had a lot to do with how we got this passed,” Roe says.

But not all doctors are unified behind the caucus. Ruiz, one of the two physicians in the House who are Democrats, says he worries because few doctors in Congress are minorities or primary care doctors.

Ruiz, an emergency room physician who was elected in 2012, says he is wary about Price leading HHS because he is concerned Price’s policies would increase the number of Americans without insurance.

Indeed, many doctors feel the caucus’ proposals will not reflect their views — or medical wisdom.

“My general feeling whenever I see any of their names, is that of contempt,” says Don McCanne, a family medicine physician in California who is past president of the Physicians for a National Health Program. “The fact that they all signed on to repeal of ACA while supporting policies that would leave so many worse off demonstrated to me that they did not represent the traditional Hippocratic traditions which place the patient first.”

This story was produced through a collaboration between NPR and Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation. Follow Phil Galewitz on Twitter: @philgalewitz.

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The Senate early Friday confirmed Rep. Tom Price, R-Ga., as the new secretary of Health and Human Services.

He was approved by a near party-line vote of 52 to 47. Democrats were concerned that the conservative congressman wants to pare down government health programs. They were also troubled by lingering ethics questions over Price’s investments.

In his new role, Price, a retired orthopedic surgeon from suburban Atlanta who served as chairman of the House Budget Committee, is expected to implement the repeal and replacement of the Affordable Care Act which his colleagues in Congress have been working on this year.

Price will oversee a $1 trillion agency, the largest budget of any Cabinet secretary. In addition to Obamacare, HHS administers the Medicare and Medicaid programs and oversees the National Institutes of Health, among other programs and agencies.

With Price’s confirmation, HHS now has as its leader a budget hawk who has proposed replacing the Affordable Care Act subsidies that are tied to income, with tax credits to purchase insurance. Tax credits are not determined by an individual’s income level.

Price also supports the proposal by House Speaker Paul Ryan to turn Medicare into what some call a “voucher” program. Under the plan, beneficiaries would receive “premium support” from the government to buy a Medicare health plan through an exchange. The private plans would compete against the traditional government-run program.

During his confirmation hearing, Price said his goal was that everyone have access to health insurance.

“What I commit to the American people is to keep patients at the center of health care. And what that means to me is making certain every single American has access to affordable health coverage,” he said.

Democrats spent hours on Thursday reading stories from their constituents about how the Affordable Care Act helped them, and tried to make the case that Price is a threat to Medicare, Medicaid and health care for people who have ongoing medical conditions.

“Congressman Price’s budget in the House cuts nearly $500 million from Medicare and turns it into a voucher program,” said Sen. Bill Nelson, D-Fla., during the 30-hour debate.

The Obamacare replacement Price proposed included offering tax credits starting at $1,200 a year to allow people to buy health insurance, boosting the use of tax-advantaged health savings accounts and limiting the tax deduction companies take for providing health insurance to workers.

Those ideas are the core of what Republicans say they want to do to replace the ACA, but the details of how big the tax credits would be, and exactly how the HSAs would be structured are unknown.

During his confirmation, Price was dogged by questions about investments he made in health care-related companies.

Price says he followed all congressional ethics rules, but his well-timed trades made it appear that he could have used his position to influence the price of stocks he owned, or that he received special treatment from companies in which he invested.

Republicans in the Senate were satisfied with his explanations however, and the former congressman will be headed to his new office today.

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Drug companies could be forgiven if they’re confused about whether President Donald Trump thinks the government should get involved in negotiating the price of prescription drugs for Medicare patients.

Just a few days before Trump was sworn in he said the pharmaceutical industry was “getting away with murder” in the way it prices medicine, and he promised to take the industry on. It was a promise he’d made repeatedly on the campaign trail.

“We’re the largest buyer of drugs in the world and yet we don’t bid properly,” he said in a news conference in early January. “We’re going to start bidding and we’re going to save billions of dollars over a period of time.”

But last week, Trump appeared to walk that vow back when he met with the leaders of several giant pharmaceutical companies at the White House.

“I’ll oppose anything that makes it harder for smaller, younger companies to take the risk of bringing a product to a vibrantly competitive market,” he said, sitting around a table in the Roosevelt Room, flanked by leaders of five large drugmakers. “That includes price fixing by the biggest dog in the market – Medicare — which is what’s happening.”

So on Tuesday, White House spokesman Sean Spicer cleared up the confusion, for now at least.

When asked during his daily news briefing whether the president is in favor of having Medicare negotiate lower prices for prescription medicine, Spicer said, “He’s for it, yes. Absolutely.”

Spicer went on to say that the U.S. should be doing what other countries do — bring the government’s purchasing power to bear to get a better deal on medicine prices.

“So his commitment is to make sure that he does what he can,” Spicer said, “and, I think rather successfully, use his skills as a businessman to drive them down.”

Current U.S. law prohibits Medicare officials from interfering in the negotiations between drugmakers and the insurance companies that administer Medicare’s prescription drug plans.

Medicare accounts for about 29 percent of all spending on prescription medicines in the U.S. each year. So, would bringing Medicare’s huge purchasing power to bear in talks over prescription drug prices actually reduce those prices?

The only government report that looks at the issue is a 2007 Congressional Budget Office study that concluded that it would have a “negligible effect” on prices.

Dr. Walid Gellad, director of the Center for Pharmaceutical Policy and Prescribing at University of Pittsburgh disagrees.

“There’s a reason why the pharmaceutical industry does not want Medicare negotiation to happen,” Gellad told NPR. “And the obvious reason is because it will lower prices.”

Gellad said the CBO report doesn’t take into account the ability the government would have to say no to some particularly high-priced medicines.

If Medicare, for example, said it would pay for only one of the two major Hepatitis C medications on the market today — drugs that cost upwards of $40,000 for a course of treatment — Gellad estimates the drugmakers would cut the price by at least $10,000 to win the government’s business.

That sort of negotiating is already allowed at the U.S. Department of Veterans Affairs.

“If Medicare were to get the same prices for drugs as in the VA you’d have billions, tens of billions of dollars of savings,” Gellad told NPR.

The Medicare prescription drug program was created in 2003; the program’s drug coverage is handled exclusively by private insurance companies. There is no direct government pharmacy coverage.

That means each insurer negotiates prices for medications separately. If one insurance company strikes a deal regarding one drug, another company may negotiate a better price for a competing medication.

A 2015 study jointly published by Carleton University and the public advocacy group Public Citizen showed that Medicare pays, on average, 73 percent more than Medicaid pays for brand-name drugs, and 80 percent more than the VA pays.

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There’s a moment in the Broadway musical Hamilton where George Washington says to an exasperated Alexander Hamilton: “Winning is easy, young man. Governing’s harder.”

When it comes to health care, it seems that President Trump is learning that same lesson. Trump and Republicans in Congress are struggling with how to keep their double-edged campaign promise — to repeal Obamacare without leaving millions of people without health insurance.

During the campaign, Trump promised to repeal and replace the Affordable Care Act immediately upon taking office. Last month, in an interview with The Washington Post, he said he had a replacement law “very much formulated down to the final strokes.”

But on Sunday, he dialed back those expectations in an interview with Fox News.

“It’s in the process and maybe it will take till sometime into next year, but we are certainly going to be in the process. It’s very complicated,” Trump said.

He repeated his claim that Obamacare has been “a disaster” and said his replacement would be a “wonderful plan” that would take time “statutorily” to put in place. And then he hedged the timing again.

“I would like to say by the end of the year, at least the rudiments,” he said.

Trump’s recent hesitation comes as Republicans in Congress tame their rhetoric surrounding the health care law.

Sen. Lamar Alexander, R-Tenn., chairman of the Senate health committee, said he’d like to see lawmakers make fixes to the current individual market before repealing parts of the law.

“We can repair the individual market, which is a good place to start,” Alexander said on Feb. 1.

He has also urged his colleagues to leave the other parts of the health care sector — Medicare, Medicaid and the employer market — alone.

Throughout the campaign, and over the six years since the law passed, Republicans in Congress have vowed to completely repeal the Affordable Care Act.

But in the time since the law went into effect, it has helped as many as 20 million people get insurance who didn’t have it before, according to the Department of Health and Human Services.

Just last week, the open enrollment period for 2017 ended and HHS reported that 9.2 million people bought insurance through the federal government’s insurance marketplace — slightly lower than last year but still a large number. About 3 million more people likely bought coverage on state-run exchanges, based on enrollment in past years.

In addition, about 10 million people qualified for health coverage because of the expansion of Medicaid in most states.

That left Trump and Republicans, the day after the election, facing the choice of fulfilling their clear promise to repeal the ACA and the reality that doing so could leave millions of people without access to health care.

At that time the public seemed to gain a new appreciation of the law once it was actually threatened with repeal. In recent weeks, several polls have shown that more people view it more favorably than they did before the election.

Another reality Republicans have had to face is that, even though they control both houses of Congress and the White House, their ability to repeal the ACA is limited. That’s because Democrats in the Senate can block bills using their filibuster power.

But laws dealing with taxes and the budget are protected from filibuster, so Republicans can roll back many Obamacare provisions because they involve tax credits and federal spending.

That leaves lawmakers having to build a new health care system that works within the general framework of the Affordable Care Act. They can get rid of subsidies to help people buy insurance, but the law creating government-run insurance exchanges, for example, will still be on the books.

That’s why Alexander and a handful of other Republicans are beginning to talk about repairing the current system. Currently, not enough young healthy people have signed up for coverage to offset the costs to insure sicker, older people. The result is that premiums have risen and insurance companies that lost money pulled out of many markets.

But not everyone is on board. House Speaker Paul Ryan, R-Wis., said last week in an interview on Fox that repairing the health care system means “You must repeal and replace Obamacare.”

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