A big question facing Republicans next year is how to pass a national healthcare reform law without taking a beating on Election Day.

Obamacare has been implemented, and 20 million Americans have health insurance through the law. That means Republicans have to figure out how they will keep their promise to repeal Obamacare without angering the people who already receive coverage from the law.

It’s a critical question for the GOP, as a matter of policy and politics, and they know from beating Democrats across the country how an unpopular healthcare bill can poison a lawmaker’s re-election chances.

“We have the competing conservative value of if you like your insurance you can keep it, and we mean it,” Sen. Bill Cassidy, R-La., told the Washington Examiner. “And the competing conservative value of the 10th Amendment, that allows states autonomy and the federal government not to tell them what to do. So, we’ve got to resolve those competing tensions.”

Cassidy, a medical doctor turned congressman who denounced former Sen. Mary Landrieu’s vote for Obamacare en route to defeating her in 2014, has been thinking about that problem for years. His solution amounts to a partial Obamacare repeal that targets the most unpopular aspects of the law, such as the individual mandate, and replaces them through alternative mechanisms designed to achieve the same goals.

He has already introduced legislation, co-authored by Texas Rep. Pete Sessions, and hopes it might drive the Republican healthcare debate over the next year.

The Sessions-Cassidy plan would eliminate the individual and employer mandates, as well as most of the minimum health benefits requirements that drive up the cost of individual plans. They would provide a universal tax credit that could be deposited in health savings accounts or spent on insurance policies.

It promotes price transparency and encourages doctors and patients to have a working relationship more like the relationship between consumers and providers in other industries.

It doesn’t repeal Obamacare’s Medicaid expansion, but it does block-grant the programs to the states and give “the option of leaving Medicaid, claiming the tax credit and purchasing private insurance,” as the Goodman Institute points out.

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It also allows states to establish a basic healthcare plan modeled on the plans available under the Employee Retirement Income Security Act of 1974, “plus a pharmacy benefit,” Cassidy said.

“You could actually keep much of what has been invested in Obamacare,” he explained. “The nice thing about this, it is not nearly so prescriptive as Obamacare.”

That makes it the rare GOP proposal that liberal healthcare experts don’t dismiss out of hand. “[It is] a bold and unconventional proposal,” Health Affairs contributing editor Timothy Jost wrote in June. “Unlike most Republican proposals, it does not purport to repeal the [Affordable Care Act].

“It would repeal the individual and employer mandates and a number of the consumer protections of the ACA, but would leave much of the infrastructure in place, including the ACA’s marketplaces and income-based premium tax credits, Medicare reforms and tax increases.”

Cassidy and Sessions would allow young people to remain on their parents’ health insurance until the age of 26 and retain the Obamacare provision that bans health insurance from refusing to sell policies to people with pre-existing conditions.

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That’s popular policy, but it leads to a thorny problem for healthcare policymakers: How do you guarantee that people won’t just wait until they are sick to buy a policy, which would quickly bankrupt insurance companies?

The individual mandate was Obama’s solution, but that’s a deeply unpopular proposal. Cassidy and Sessions get around that problem by allowing states to enroll their citizens in the basic healthcare plan automatically, unless the individuals opt out of the program.

“If they’re somebody who wants to be out, absolutely you respect that, the patient has the power,” Cassidy said. “Assuming the state legislature opts for this and the patient will be enrolled in the standard plan even if they do nothing, we restore what is called the law of big numbers. You have all the young invincibles enrolled and you can spread the cost of someone’s illness over the many.”

On the other hand, states that want to remain in the Obamacare system would be allowed to do so. “Conservatives have always said, ‘If you like your insurance you can keep it,’ and unlike Democrats we mean it when we say it,” Cassidy said.

“There’s actually some states that claim that Obamacare is working for them. God bless them. What we say is, if a majority of the state wishes to keep Obamacare, they can. They can opt to stay in Obamacare because, by golly if Californians want to keep that coercive, top-heavy system, let them do it.”

Taken together, the Cassidy-Sessions plan introduces some of the traditional healthcare reforms that conservatives have rallied around, even if it stops short of the “root and branch” repeal that Senate Majority Leader Mitch McConnell, R-Ky., called for during the 2014 midterm elections.

Whether most Republican lawmakers, and the conservative voters who can dictate the winner of a GOP primary campaign, view that as a fulfillment of their campaign promises remains to be seen.

Cassidy feels confident that his plan can function as a blueprint for the Republicans’ healthcare reform debate.

“When President Trump spoke of a full repeal, everyone knows he cannot go back in time and recover those billions that have already been lost on co-ops, and since businesses have already invested the money in figuring out how many calories are in a Five Guys double burger, that’s been done,” he said.

“So, within that construct of how we as conservatives approach things, we repeal and replace. My hope — because I think it’s better for patients — is that every state repeals Obamacare and replaces it with the Cassidy-Sessions plan, but I’m not going to do what the Obamacare people did, which is to tell them what to do, by golly, whether you want it or not, and if not I’m sicking the law on you.

“That is not a conservative principle,” Cassidy continued. “So, there are competing principles and we think we navigate it. And frankly, I think almost all end up replacing it, so we achieve it without being coercive.”

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