WASHINGTON — As he pushes to "repeal and replace" President Obama's healthcare law, former Massachusetts Gov. Mitt Romney has turned to proposals that could alter the way hundreds of millions of Americans get their medical insurance.
In public, Romney has only sketched the outlines of a plan, and aides have declined to answer questions about the details. But his public statements and interviews with advisors make clear that Romney has embraced a strategy that in crucial ways is more revolutionary — and potentially more disruptive — than the law Obama signed two years ago.
The centerpiece of Romney's plan would overhaul the way most Americans get their health coverage: at work. He would do so by giving Americans a tax break to buy their own health plans. That would give consumers more choices, but also more risk.
Critics and independent analysts say the impact would probably leave a larger number of Americans without insurance.
Conservative healthcare experts say changes along those lines would bring the benefits of competition to healthcare and that basic restructuring is needed.
"There are significant changes that should be made," said Dr. Scott Atlas, a senior fellow at the Hoover Institution who is advising the Romney campaign.
Romney's plan follows a lead set by President George W. Bush, who unsuccessfully pushed for a healthcare overhaul. It adopts proposals long championed by conservative healthcare experts.
It also sharply contrasts with Romney's last foray into healthcare reform. As governor of Massachusetts, Romney successfully pushed a law that guaranteed coverage for all state residents and included a requirement that people buy insurance — an individual mandate similar to Obama's.
Romney moved away from that plan during the Republican primaries and has shown no signs of returning to it. Indeed, his emerging plan would make it all but impossible for any state to follow Massachusetts' example.
While offering consumers more choices, Romney's plan would give companies strong incentives to stop providing insurance to workers. It also would overhaul the 46-year-old Medicare and Medicaid programs for the elderly, poor and disabled.
The plan could swell the federal deficit; a similar plan backed by Sen. John McCain (R-Ariz.) during the 2008 presidential campaign would have cost more than $1 trillion over 10 years, on par with the price tag for the Obama healthcare law.
Romney now regularly criticizes Obama's healthcare law as government overreach and an attack on American free enterprise.
"It's easy to forget how often candidate Obama assured us under 'Obamacare,' nothing in our insurance plans would have to change," Romney said recently at the National Rifle Assn. annual meeting.
But unlike Obama's healthcare law, Romney's plan could fundamentally change the rules for the more than 150 million Americans who get insurance through their employers. These workers get a large tax break because their health benefits are not taxed. Businesses that provide insurance also get a break because their contributions to their employees' health plans aren't taxed.
In place of that system, Romney would give Americans a tax break to buy their own health plans, regardless of whether their employers offered coverage.
"This gets greater consumer choice so that people can buy what they want, not just what their employer wants to give them," Romney said last year while explaining his plan at the University of Michigan.
Conservative healthcare experts offer several reasons for such a change. The main one is that the tax law needs to be revised to bring free-market competition to the healthcare system.
"It is absolutely essential if you are going to reform the health insurance market to change the tax treatment of health insurance," said Robert Moffit, a senior fellow at the Heritage Foundation. "It is the 800-pound gorilla in the healthcare debate."
Moreover, the current system effectively discriminates against Americans who do not get health benefits at work. They must buy coverage on their own and do not get the same tax break.
Many experts think the current system also pushes up healthcare costs because it gives employers an incentive to provide generous health benefits, which are tax-free, rather than pay higher wages, which would be taxed.
Romney would make a parallel change in Medicare — giving seniors the ability to shop for their own health plans with vouchers rather than use the existing government-run program. That proposal, which resembles a budget plan proposed by Rep. Paul D. Ryan (R-Wis.), would represent the biggest change to the federal entitlement program since its creation in 1965.
Supporters argue that with Medicare, as with insurance for working-age adults, free-market competition would lower costs. But the shift could force seniors to pay thousands of dollars more for their care, according to analyses of similar proposals by the nonpartisan Congressional Budget Office.
The third leg of Romney's plan would convert the Medicaid program for poor and disabled Americans into a series of block grants to states.
The budget office estimates such a move would cut hundreds of billions of dollars from the healthcare safety net and force major new limits on care. It would also effectively make another Massachusetts experiment impossible. Romney's plan as governor depended on a 20% bump in federal aid that the state received.
Conservative healthcare experts think that scaling back government and letting more people shop for their own coverage would drive down prices. Insurers would be freed from regulation and consumers would get an incentive to pick lower-cost options, they say.
But this approach is largely untested on the scale Romney has discussed. Critics say it would put the health insurance of millions of Americans at risk.
For example, if workers had the ability to shop anywhere for a health plan, and if companies no longer got tax breaks, some employers would likely stop providing health coverage. That might be fine for young, healthy workers who could buy plans on their own. But older or sicker workers would lose the protection they now receive by buying insurance within a group. If young adults opted to buy low-cost plans that provided limited benefits, prices could rise sharply for middle-aged workers who are more likely to have chronic health problems.
Under the McCain plan, more than 9 million fewer people would have received health benefits through their jobs, according to an estimate from the Lewin Group, a healthcare consulting firm.
Giving tax breaks to all Americans to get health insurance also can cost a lot.
"It is basically impossible to do this in a way that doesn't cost money," said Gail Wilensky, a former Medicare and Medicaid administrator who has advised several GOP presidential candidates.
When Bush offered his plan, he proposed to pay for it in part with more than $400 billion in new taxes on American workers and businesses. Romney has not said whether he plans to include any new taxes in his plan.
The Romney campaign declined to answer a series of detailed questions about how his healthcare plan would be financed, how many people would be affected and how it would affect medical bills, healthcare providers and sick Americans without health coverage.
"He will continue to fill in the details as the campaign progresses," spokeswoman Andrea Saul said.