Republicans, who today narrowly won a House vote aimed at dismantling key parts of Obamacare, have opened themselves up to being cast as heartless by political foes and many constituents. Experts estimate that the legislation would result in lost or reduced coverage for millions of Americans.

So why has the GOP pushed forward? Partly, of course, it’s the politics of a highly polarized era. But another prominent factor is lawmakers’ guiding principles.

As Republicans look at a health-care system that’s imposing ever higher costs on both average Americans and on the federal budget, they argue that principles like free-market competition and consumer choice could prove vital to making health care more affordable and accessible. In tandem, other conservative values are being championed: limited government, turning power back to the states, and curbing federal deficits.

And they are impassioned about it.

Rep. Dave Brat (R) of Virginia calls freedom the “ultimate American value” and says “that value produced the best pharmaceutical system, the best hospital system, the best insurance system, the best everything.”

The nation’s challenges with spiraling health costs, Representative Brat says, are rooted in over-regulation by the federal government. “We’re ruining it,” he says, as “everything in the world is run out of this city.”

Although those views generally resonate across the Republican base, the GOP effort will face a values test as the bill faces a tougher path in the Senate – and increased public scrutiny. Freedom is one bedrock value for Americans, but not the only one.

And health care, more than most issues, hinges around questions of compassion: In the case of this bill, is it right that as many as 24 million Americans could lose their coverage?

More basically, constituents are asking themselves how it will affect their pocketbook and their health.

Late-night TV host Jimmy Kimmel struck a chord with many Americans with a monologue Monday night that went viral online, telling viewers why he had missed a string of shows – that his newborn son had undergone surgery after doctors diagnosed a rare condition which they said was life-threatening.

"No parent should ever have to decide if they can afford to save their child’s life," he said. "It just shouldn’t happen. Not here.”

Varied views among Republicans

President Trump railed against the Affordable Care Act, known as ACA or Obamacare, during the election campaign. But he also promised to improve coverage for Americans.

Shrinking government, shifting care for the poor (Medicaid) toward the states, and loosening federal mandates on insurance are all top priorities for most Republicans in Congress – especially those in the Freedom Caucus wing that rejected an earlier version of the bill as too liberal.

Yet lawmakers also know their constituents have very immediate concerns on their minds: What will happen to their coverage, their premiums, their out-of-pocket costs? Party moderates are concerned about striking the right balance.

“I think everybody in this country should have access to affordable health-care coverage. And I think that a policy that ensures that if you have preexisting conditions you will not face price discrimination is essential,” Rep. Ryan Costello, from a Pennsylvania a swing district outside Philadelphia, said in an interview on May 2. He voted against the bill on Thursday.

Key points in the legislation

Although labeled by Republicans as a key step toward “repeal and replace,” the bill leaves much of Obamacare intact. It does, however, make major changes that critics say the result would be to undercut the viability of state-level marketplaces (exchanges) for buying insurance and to reduce Medicaid coverage by 14 million people.

Key points in the legislation include:

Removing the tax penalty on individuals who do not sign up for minimum insurance.

Maintaining the requirement that insurers grant policies regardless of medical history, but allowing waivers for states to set up “high-risk pools” for people with pre-existing conditions. (Federal subsidies would help cover people in those pools.)

Adjusting subsidies and the regulation of premiums so that insurance becomes more affordable for young people but costlier for older people.

Cut about $880 billion from Medicaid by shifting toward a per capita allotment and giving states greater responsibility.

The nonpartisan Congressional Budget Office (CBO), looking at an earlier version of the plan, estimated it would reduce federal deficits by $337 billion over the coming decade, but would leave 14 million more Americans uninsured in 2018 and 24 million by 2026. Most of the initial 14 million would come from people opting out of the individual mandate, the CBO said.

Democrats say the bill turns its back on principles most Americans embrace.

“We believe – in the values debate – that health care is a right for all Americans, not just a privilege for the few,” House minority leader Nancy Pelosi (D) of California said recently. “Here they are – giving a tax break. And ironically, many of the people who will lose their health care voted for President Trump, live in red areas. Much of the money that will go to richest people in America are in blue areas. Now, isn’t that something?”

As the vote was being taken Thursday, the Democratic leadership said the bill will also endanger the quality of employer-based health plans, by allowing employers to choose the benefit requirements from any state, including ones that might lower their benchmarks under a waiver.

Even after passing the House 217-213 on May 4, the road ahead in the Senate is uncertain.

Moderate Sen. Susan Collins (R) of Maine has co-authored a bill with fellow Republican Sen. Bill Cassidy of Louisiana, who is a doctor. Their bill would allow states that want to keep the ACA to be able to keep it, while others could take ACA money and use it to increase health care coverage.

Where many Republicans promote “universal access” to affordable insurance rather than the goal of universal coverage, the effort by these two senators may reflect how Obamacare has shifted America’s goalposts on that point.

“Affordability and access have always been key Republican values when it comes to designing a health care system,” Senator Collins said in a recent interview. “There is increasing awareness that those two issues are linked to coverage and that if you don’t have insurance, access is going to be more limited.”

She said “one of our goals is to expand coverage and help reduce the 30 million Americans who are still uncovered despite years of the Affordable Care Act.”

Delegating power to the states

Even to some health-care experts who are fans of conservative-style reform, it looks like Republicans are still feeling their way on how to blend free markets and fiscal discipline with widespread coverage and security.

But conservative experts on health policy say that implementing more competitive markets, consumer choice, and empowerment for states could make a positive difference. Today health care accounts for nearly one-fifth of the nation’s economy, a proportion that is rising.

In many ways, the debate over what to do about rising costs centers around just how different health care is from other goods and services. Most consumer choices don’t have life-or-death implications, but conservatives say that doesn’t mean the task of providing care needs to become increasingly government-driven.

Paul Howard, a health policy expert at the Manhattan Institute in New York, sees value in the ideal – dating back to the drafting of the Constitution – of delegating much to the states, which are already in the business of regulating the industry.

“We need to give incentives for those markets to work as well as possible … to encourage competition,” Mr. Howard says. “Federalism could allow blue and red states to have their experiments within a common fiscal framework.”

Other options for controlling costs

Across the spectrum of policy experts, however, many are skeptical of how big a role consumer choice can play. One Republican goal has been to lop off some of the elements that basic insurance plans must include, for instance, and then let people choose if they want to add additional coverage.

“A whole bunch of people didn't think they need mental health care” (something included in Obamacare-compliant health plans), until a need arose, says Gary Claxton of the Kaiser Family Foundation, which focuses on health-care research.

He and other experts say competition has been diminished by a trend of hospital consolidation.

But many experts see other avenues for cost control, including a nascent shift toward “bundled payment” for each episode of care, rather than letting providers charge incremental fees for each test or service.

Get the Monitor Stories you care about delivered to your inbox. By signing up, you agree to our Privacy Policy

And although government regulation is anathema to Republican values, it has been used to bring down the cost of everything from prescription drugs to medical procedures. “Compared to other countries we regulate far fewer prices,” says Mr. Claxton.

Staff writer Francine Kiefer contributed reporting from Capitol Hill.