Jayne O'Donnell

USA TODAY

After six years of threats to repeal the Affordable Care Act, House Republicans released the broad outlines of what they would replace it with Wednesday and even business groups are uneasy.

The sweeping policy proposal doesn't include any estimates of what it would cost, but it does shift a tax on generous benefits to employees, rather than companies, as the ACA does. The ERISA Industry Committee (ERIC), which represents most of the largest employers, says that's a mistake.

"The real-world consequences would mean lower pay for hardworking taxpayers. said James Gelfand, ERIC's senior vice president of health policy,

"The policy rests on the myth that employer-sponsored health insurance is overly generous — that working families’ benefits need to be reduced, and that more costs need to be shifted to employees," Gelfand added in a statement.

Worse yet, says health care economist John Goodman, are the political optics of taxing "ordinary workers" instead of drugmakers, medical device makers and higher-earning individuals.

“Rather than taxing benefits, we encourage Congress to focus more on removing payment incentives for health care providers and suppliers that drive unnecessary health care spending," said Brian Marcotte, CEO of the National Business Group on Health.

Nearly 13 million people enrolled in ACA plans for 2016

Marcotte said his group would rather see the Centers for Medicare and Medicaid Services move more quickly to paying for the quality rather than quantity of treatments provided to Medicare patients. He specifically cited "financial incentives that encourage providers to use more expensive care in more expensive settings when lower cost alternatives of equal or better quality exist.” Drugmakers and patient groups they fund are currently fighting a proposed CMS experiment to reduce what some doctors are paid to administer injectible and infused drugs.

The proposal, which House Speaker Paul Ryan and four other House Republican leaders unveiled Wednesday, would keep some of the ACA provisions that are broadly embraced, especially the prohibition on discriminating against those with preexisting conditions and allowing young people to stay on their parents' insurance until they are 26.

To those who have suggested his party has been far better at calling for repeal of the ACA than saying what they'd replace it with, Ryan said, "Here it is, a real plan in black and white, right here."

Instead of the way the ACA "made some people pay more, so others can pay less," Ryan said the GOP proposal allows consumers to "pick a plan that works for you."

The new plan would also expand and encourage the use of health savings accounts — tax-free money that people can use to pay for their own care.

"We think if you want to give Americans more freedom and more control (over their healthcare), then HSAs are a critical part of that," said Rep. Kevin Brady, a Texas Republican and chairman of the House Ways and Means Committee.

Insurance would be "like a health care 'backpack' that provides every American access to financial support for an insurance plan chosen by the individual and can be taken with them job-to-job, home to start a small business or raise a family, and even into retirement years," according to the plan.

Feds target young adults for health insurance coverage outreach

In an effort to make insurance more affordable to young people, insurers would be able to charge older adults five times more than young people, up from the current limit of three times.

What would go:

• The expansion of Medicaid to all the low income residents of the now-32 states including Washington, D.C. that have opted in with the addition of Louisiana starting July 1. It would be replaced with a system that gives states far more flexibility to design benefits, most likely through block grants.

• The individual mandate that everyone have insurance and the penalty if you don't.

• The restrictions on selling — and keeping — your insurance across state lines.

Robert Greenstein, president of the Center on Budget and Policy Priorities, noted that by eliminating the individual mandate the GOP plan would increase the chance healthier people would drop coverage, which would lead to higher premiums for everyone. Despite what Greenstein called the GOP's "blithe claims" that states could simply make Medicaid more efficient, he says the large federal funding losses would require either much high state Medicaid spending or cuts in eligibility, benefits and payments to doctors and hospitals. That could cause millions to lose Medicaid coverage or at least necessary benefits, he says.

The GOP proposal would also loosen anti-discrimination restrictions on company wellness programs, which Brady says are "wildly popular yet under attack by this Administration."

Kip Piper, a former state and federal Medicaid official who is now a consultant, called the plan "decidedly conservative but a carefully constructed blend."

"Instead of attempting a Don Quixotesque mass repeal of the ACA or proposing separate bills dealing with pieces of the ACA, the Speaker’s effort represents a more traditional policy-driven path," says Piper. "It better recognizes the complexities of federal policy and the insurance market and works to better explain GOP principles, the rationale behind policies, and how to fix the ACA."