Donald Trump and his pick to lead the Obamacare repeal effort, Rep. Tom Price, share a vision that the current health care system needs to be completely uprooted.

But the two men have articulated wildly divergent visions for what comes next — and that's making it hard for Hill Republicans to figure out where to start on a coherent replacement plan once Obamacare is gone.


Over the weekend, Trump said he wants to substantially expand coverage once Price is confirmed as Health and Human Services secretary — "insurance for everybody" as he put it to the Washington Post. But as a House member and former chairman of the House Budget Committee, the Georgia Republican wrote one of the most conservative visions for health care, although his plan never included universal coverage as a stated goal.

Congressional Republicans are caught in between, racing to repeal Obamacare while receiving mixed signals from the incoming administration about what will replace it. Several key Republicans have already indicated Price's approach won't undergird the legislative process.

Senate Finance Chairman Orrin Hatch (R-Utah) stopped to greet Price warmly late last week, then said in an interview that Price's bills from last Congress aren't indicative of where Republicans are at.

“No. I don’t know what it will be. We’ve got a new element in Donald Trump,” said Hatch, the Senate Finance Committee chairman. “We still don’t know exactly what they want to do.”

GOP lawmakers, including Price, stress they are less concerned about matching Obamacare's coverage gains, which drove the nation's uninsured rate to a historic low of 9 percent. They would rather people have access to affordable insurance only if they want it, hoping to avoid Obamacare's individual mandate.

But Trump indicated that he wants his plan to match Obamacare, if not exceed it, when it comes to expanding health care coverage. One of the chief GOP criticisms of Obamacare is that while it expanded insurance coverage, high deductibles and narrow networks reduced actual access to doctors and hospitals.

Some Republicans expect Price to take a different tack when he takes a post in the executive branch.

“I don’t know what his bill said two years ago. My guess is that Tom Price as head of HHS will approach things vastly different than Tom Price who was introducing legislation that was never going to become law, OK?” said Sen. Bob Corker (R-Tenn.).

Price’s plan would provide consumers tax credits to help them buy insurance coverage — everyone would get at least $1,200 a year, increasing with age, regardless of income. No one could be denied coverage by an insurance company as long as they maintain coverage — otherwise insurance companies could deny coverage or charge a significant penalty for entering the insurance market post-Obamacare, a point Democrats already strongly oppose. Health Savings Accounts would also be expanded.

A number of Senate Republicans echoed Corkers's statement, saying they do not view Price's plan as the starting point for the GOP. But thus far, Hill Republicans have not echoed Trump's call for all Americans to enjoy access to insurance either.

And in the House Republicans are much more receptive to their colleague’s plan. And because Trump selected Price as his HHS secretary, they view his bill as a logical jumping off point.

“Dr. Price was a leader of our better way agenda on health care and helped shape ... much of what the House proposal is,” said House Ways and Means Committee Chairman Kevin Brady. “So I feel like we’re heading in the same direction.”

Though Republicans said very broad discussions with Price about Obamacare are already underway, those discussions come amid a tug-of-war between the House, Senate and incoming administration over where to start. That discussion was further jolted by Trump's comments that suggested he wanted to eliminate a health system where "if you can't pay for [insurance], you don't get it."

A number of GOP senators want Price to explore executive orders that can be made to change Obamacare and winnow down essential health benefits required in insurance plans before they forge ahead on an a broader alternative. And when they do, it's the preference of many senators to seek a middle ground between Price's right-leaning plan and Trump's goal of expanding access to health care.

With a supermajority required in the Senate to pass a new healthcare law, Republicans in the upper chamber say they are in the driver’s seat to begin writing a replacement. Most of the Republican health care plans — including Price’s — have similarities such as incentives to buy insurance and the ability to sell insurance across state lines. But there’s also recognition that the GOP is going to have to come a lot closer to the middle to get any Democrats on board.

Sen. Bill Cassidy (R-La.) wants to allow blue states to essentially keep Obamacare if they believe it is working, which may be a point of entry for Democrats to come on-board. Asked about where to start, he responded: “I’d like to pick up a Bill Cassidy bill and start with that.”

“There’s a lot of common ground between the two of us. If you read the two it’s clear we plagiarized each other. On the other hand, I like that ours returns it to the states,” Cassidy said. “There’s features in our bill that I think are superior.”

Many House members support Price’s conservative vision for health-care reform and pay little heed to the whims of Senate Democrats, who say they won’t even engage with Republicans until the party coalesces around a plan. Price, who was one of the first Republicans to come forward with an alternative to Obamacare, has said in the past that he isn’t wedded to his own plan, called the Empowering Patients First Act. And he has adjusted it several times over the years.

Rep. Mark Meadows, chairman of the conservative House Freedom Caucus, said he’d prefer the House Republican Study Committee’s bill, put together by Rep. Phil Roe (R-Tenn.).

“Dr. Price’s plan, Dr. Roe’s plan or a combination thereof— I probably favor Dr. Roe’s plan more than Dr. Price’s but we need to decide so we can start debating the merits,” Meadows said.

But Energy and Commerce Committee Chairman Greg Walden (R-Ore.), whose committee covers much of any health plan, wouldn’t commit to using Price’s – or any other plan – as the starting point for the debate.

"I’m not saying that you take the Price plan and run,” he said.

In many ways, Trump is getting ahead of himself in suggesting that once Price is confirmed things will begin to move quickly. Price isn’t even on track to be approved by the Senate until February given Democrats’ opposition and the Senate’s glacial pace. And that's making it tough for him to get in the weeds.

“He can’t be dealing with these issues as a nominee. So when is he going to be confirmed?” Corker said. “There’s so much he can do with a pen. You don't have to pass legislation. He can modify how we look at the 10 essential benefits. He can give the states more flexibility on the Medicaid program. There’s a lot that he can do to really ease the way for reform. “

Then there’s the general disarray for a party that mostly thought it would be out of power after the election. Republicans passed a budget resolution that allows them to repeal the law through the reconciliation process — and evade the Senate’s supermajority requirement. And they also have taken steps to get on the same page, with Senate Majority Leader Mitch McConnell laying out the sequencing in private meetings last week, said Sen. Roger Wicker (R-Miss.).

But Republicans still haven’t figured out how long the transition period between a vote to repeal the law and its enactment would last or exactly when the repeal vote will even occur.

“Obviously we can’t give you a specific date,” Wicker said. “We are going to get [Price] confirmed and then the House and Senate members that are taking the lead on this issue are going to then deal with the secretary.”

And that doesn’t even get into replacement. In interviews lawmakers in both chambers stated their broad goals that are shared by Republicans and some of which are in Price’s plan: High-risk pools for people with pre-existing conditions, expanded health savings accounts and selling insurance across state lines. But that probably won't be enough to fully replace Obamacare's insurance levels and certainly won't get to where Trump said he wants to go.

Price "had a bill. A lot of our guys had bills. There will probably be elements of all of them in the final product," said Sen. John Thune (R-S.D.). “But how it all gets synthesized is the question."