WASHINGTON – Now comes the hard part.
One day after voting to repeal President Barack Obama's landmark expansion of health insurance coverage, House Republicans go to work on replacing it.
Out with mandates, the requirements in the law to carry health insurance coverage. In with special purchasing pools for people whose medical conditions render them uninsurable.
Out with cuts to Medicare Advantage, the private alternative to the traditional health program for seniors and disabled people. In with limits to jury awards in medical malpractice cases and stricter restrictions on taxpayer funding for abortions.
The House will vote Thursday on a measure directing four committees — Ways and Means, Energy and Commerce, Education and Workforce, and Judiciary — to work out the Republican vision for health care.
Like the repeal bill itself, the "replace" part would require the acquiescence of the Senate. Democrats still in charge there say they plan to simply ignore the House. The prospect is for months of maneuvering.
Meantime, lawsuits by more than half the states challenging the constitutionality of the law are advancing through the federal courts.
Don't look for House Republicans to follow the same game plan Democrats used a couple of years ago by putting together sweeping legislation to address the cost and coverage problems of the health care system.
Instead, they'll try to pick off unpopular provisions of Obama's law, such as the 1099 tax provision that would require businesses to report to the Internal Revenue Service purchases of $600 or more. And they'll attempt to advance their own alternatives on issues like malpractice.
"We will begin ... to implement step-by-step, common-sense reforms that actually lower the cost of health care and actually respect the doctor-patient relationship," said the Ways and Means chairman, Rep. David Camp, R-Mich.
Whatever Republicans do, Democrats say they're confident the public will ultimately conclude it doesn't measure up to the law already on the books, an expansion of society's safety net sought by Democratic presidents going back to Harry Truman.
It would expand coverage to more than 30 million uninsured people, reduce costs for Medicare recipients with high prescription drug bills and bar insurers from denying coverage to people with health problems. Starting in 2014, most Americans would be required to have health insurance. Millions of middle-class households would be able to purchase a plan through new state-based insurance pools, with tax credits to make premiums more affordable.
"This (repeal) bill will not become law," said Rep. Sander Levin of Michigan, ranking Democrat on the Ways and Means Committee. "We on this side are on the offense on this issue. We are an American truth squad. (Repeal) will not prevail."
Republicans say there's no timeline for their "replace" legislation, but if they're serious, they'll have to start advancing specific proposals by the summer.
The likeliest prospect Republicans have for success in the short term lies in taking on the 1099 tax reporting requirement for businesses. It's been widely criticized as a paperwork nightmare. Even the White House wants to scrap the provision, and the Treasury Department has already taken action to limit its scope. But the two political parties disagree on how to go about undoing the requirement, so an early resolution seems unlikely. Lawmakers have time; it doesn't take effect until next year.
GOP leaders are working on the assumption that their repeal bill will not become law, but nonetheless they see it as an important marker.
"Unless we repeal the law in the House, we don't have any credibility to do anything," said Rep. Joe Barton of Texas, a senior Republican on health care issues. "This establishes Republicans' credibility to negotiate and deal with the Senate and the president."
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