Donald Trump has pledged to provide "insurance for everybody" and his nominee for Health Secretary Tom Price told Senators he shares the president-elect's goals at his confirmation hearing on Wednesday. But the heart of the GOP's efforts to retool the health care system is in Congress, where less visible personalities like Sen. Bill Cassidy (R-LA) have to turn these broad ideas into specific legislation and corral the votes to pass them.
Cassidy is only a freshman, but he's already playing an outsized role in Republican efforts to repeal and replace the Affordable Care Act thanks to his background. He worked as a physician in Louisiana treating low-income residents before coming to Washington and has made health policy a focus in office.
Last year, he introduced "The World's Greatest Health Care Plan" with Rep. Pete Sessions (R-TX) a detailed replacement plan for the ACA that would allow states to keep the law's basic structure in place or opt into a new system where patients would receive tax credits to buy care based on age and geography. This month, he plans to introduce the "Patient Freedom Act," which takes a similar approach (albeit with a more sober name). Cassidy believes his bill would ultimately cover more Americans than Obamacare by automatically enrolling consumers in a barebones plan, which they'd then have the option to leave.
NBC News sat down with Cassidy in his office in Washington to talk about his latest proposals, Donald Trump's boasts, and the prospects for a bipartisan deal with Democrats. Here is that discussion, edited for length and clarity:
Q: Did you call your proposal "The World's Greatest Health Care Plan" to a get a certain president-elect's attention?
CASSIDY: Actually, to get the press attention. We [first] introduced the Patient Freedom Act at the time of the King v Burwell decision and the press never picked up on it, and the press would keep writing 'No one has offered a bill, no one has submitted a bill.' Clearly our incoming president has a knack for marketing, so we took a page.
Q: One thing that stands out is you would allow individual states, if they want, to keep some version of Obamacare in place.
CASSIDY: One of the clear problems of Obamacare is that it was perceived, I think rightly, as one party forcing its vision of how healthcare should be upon the rest of the country. The people in the northeast and west coast claim it's working for them, God bless you. It's not working in Arizona and for Louisiana and other states where we're down to one insurance company in most parishes and counties and premium increases have been double digit and in some cases triple digit in one year.
Q: What is the biggest difference consumers would notice if their state opted into your alternative program?
CASSIDY: Those that are eligible would get a direct credit to an account that they would either already have or would be set up for them. If they did nothing -- think of the person living under the park bench or the typical 28 year old male who's not even aware of insurance issues -- there would be a standard policy. There would be a safety net, if you will. But if they were active they could manage it and really draw benefit out of it.
So you reward the folks who work hard, but you also take care of the folks who, for whatever reason, don't pay as much attention. I like to say we create a safety net without creating passivity.
Q: Instead of a mandate, states would have the ability to automatically enroll people in a standard insurance plan unless they chose to opt out. What kind of coverage could they expect?
CASSIDY: You would have a health savings account with a pharmacy benefit and catastrophic coverage. Unlike a Bronze Plan [on the ACA exchange] where you have a $6,000 deductible -- so you're out of pocket $6,000 dollars before your child's earache is covered at the urgent care center -- we would pre-fund a health savings account. With health savings accounts, people become shoppers, so when we give them the tool of price transparency they're going to go to the urgent care center where they actually get the better deal.
Q: The president-elect gave an interview with the Washington Post recently where he said he wanted both "insurance for everybody" and "much lower deductibles." That seems very difficult to do.
CASSIDY: Our plan achieves it.
Q: You don't think he's over-promising?
CASSIDY: We spoke to an insurance group recently and they said our model -- everyone enrolled unless they chose not to be -- could, in and of itself, lower premiums by 20 percent, because you now have the law of big numbers. It's not just the sick and old signing up ... you get everyone in. So that's a 20 percent reduction right there, but you've done it by expanding coverage. I would argue the way you achieve one promise is by fulfilling both.
Q: One thing some conservatives say is that when you talk about a goal of covering more people or even covering everybody, you're ceding the playing field to Democrats. They worry once you've ceded that premise, you need something similar in scale to Obamacare to achieve it. What would you say to skeptics on the right?
CASSIDY: There's nobody across the spectrum who says you shouldn't have access [to health care]. Okay, so what's the best place for access? Should it be through an ER, in which case you only go when your high blood pressure is so bad that you're having headaches and blood in your urine? Of course not. It's better to have a primary care physician who will manage your high blood pressure so you don't get into renal failure.
What I'm going to disagree with is you assume, if this is the case...that you must have as much of a benefit package as the left. Again, if you have a health savings account with a catastrophic policy and a pharmacy benefit, that is not telling insurance companies you have to cover this and you have cover that. As soon as you make a benefit mandatory, the providers of those benefits are going to raise prices.
Q: So you think, in the end, any replacement plan -- including yours -- would be significantly cheaper?
CASSIDY: Obamacare is imploding and the insurance markets are going into death spiral. Long term, the only way to bail that out is a lot more taxpayer dollars, and that's good money after bad. So what I would say is, I don't know where we start relative to the expense of Obamacare, but I know the trajectory going forward is a lot less.
Q: You have been critical of the idea of repealing Obamacare without coming up with some replacement first.
CASSIDY: I think it would be better to say I've been critical of repealing Obamacare without having a plan as to how we're going forward that can be concomitantly implemented.
Q: So do you just mean there's a written blueprint everyone can agree to? Or something that can actually pass muster with the necessary votes at the same time you pass repeal?
CASSSIDY: Yes. [pauses, laughs]. People want Obamacare repealed, I'll just tell you. Since it passed, the public has been voting out politicians who supported Obamacare. and they don't trust Washington, DC to delay. They think unless it happens soon, it will never happen. I get that and I agree with them.
So as we repeal, we set the stage for replace. [Republicans] generally support the idea someone can stay on their parents' policy until they're 26, so when you repeal you don't repeal that and you've integrated it into your replace. There's a section of Obamacare called 1332 which would allow states' waivers to do their own thing….by not repealing that, you've actually set the stage for replace.
It is good to have general principles and to have an outline that incorporates those general principles so as we go forward it's plugged in at the appropriate moment.
Q: It sounds like what you're saying is a full replacement doesn't have to be voted on immediately at the same time as repeal.
CASSIDY: No, because the full repeal won't occur at once. If step by step we do one and then the other, we're both fulfilling the promise to the American people, having that sense of urgency they want to see, but with interaction from stakeholders putting together something that works for people.
Q: Here are two fears raised about repeal and delay: One, that Democrats perhaps refuse to negotiate afterwards and Republicans are forced to extend this delay over and over again. Or two, Democrats refuse to negotiate, no deal can be worked out, and the insurance market collapses. I'm sure you saw the CBO estimated that 18 million would lose insurance in the first year if the mandate and subsidies sunset. Are you worried about either of these scenarios coming to pass?
CASSIDY: You acknowledge that they can, but as long as you feel like there's momentum in the right direction, it's an acknowledgement, but it's not a fear.
Q: On that note, I saw you quoted saying you're already talking to some Democrats about a possible bipartisan deal. How's that going? Do you get a sense of what their baseline is?
CASSIDY: You can look at the map, I don't have to tell you. There are a number of blue states with one insurance carrier on the exchange and you can look at their premium increases. They know there's a problem. I'll note that Hillary Clinton said there are problems.
So they're open. Right now, they're under tremendous pressure from their wing not to collaborate or cooperate with Republicans and I get it, we need to show that we have our act together. But if we can show we have our act together and in good faith we're coming forward with a plan which allows different states to respond differently to the pressures, I like to think they'll put party second and patients first.