Rep. Paul D. Ryan (R-Wis.) and other conservatives have long favored replacing… (Riccardo S. Savi, WireImage )
Reporting from Washington — Republican activists, increasingly optimistic they can win the White House and Senate next year, are beginning to lay the groundwork for a multi-pronged campaign in 2013 to roll back President Obama's sweeping healthcare overhaul.
The push includes an effort to pressure Republican candidates to commit to using every available tool to fully repeal the law, a tactic pioneered by conservative activist Grover Norquist, who made an anti-tax pledge de rigeur for GOP politicians.
Other conservative healthcare experts are developing an alternative to the law, an effort that could protect Republicans from past critiques that their healthcare plans left tens of millions of Americans without medical coverage.
"The window for action comes and goes," said Tom Miller, a senior fellow at the American Enterprise Institute, one of several conservative groups involved in the effort. "We need to be ready."
None of the leading Republican presidential candidates has offered a healthcare plan. And conservative experts think the GOP needs a strategy to quickly dismantle the current law and replace it before all Americans are guaranteed insurance coverage under the law.
Some activists are so concerned that Republicans will miss their chance that they are trying to lock GOP candidates into using a controversial parliamentary tactic known as budget reconciliation to circumvent Senate Democratic opposition to repeal.
"This needs to be a threshold question for both presidential and Senate candidates," said Michael Needham, head of Heritage Action for America, an advocacy group affiliated with the Heritage Foundation that supports many tea party positions.
A Republican replacement plan could build off a 2009 House GOP plan, said James Capretta, a former George W. Bush administration official who is developing a replacement strategy.
The 2009 Republican bill — which required $61 billion in new spending over 10 years compared with more than $900 billion in Obama's plan — relied largely on freeing insurers from government requirements.
That would slow rising premiums for many consumers, according to the nonpartisan Congressional Budget Office. But deregulation would leave Americans with less comprehensive insurance and could mean higher bills for sick consumers, the budget office estimated.
At the same time, the GOP plan offered little help to Americans who couldn't afford coverage and would have left 52 million Americans without health insurance in 2019, virtually the same number as today.
"We will have to do better," said Capretta, who is working on the replacement legislation at Partnership for America, a new advocacy group led by James Wootton, a past head of the U.S. Chamber of Commerce's Institute for Legal Reform.
Capretta and many conservatives, including House Budget Committee Chairman Paul D. Ryan (R-Wis.), have long favored replacing the current healthcare system, in which most Americans rely on their employers to get health insurance, a system perpetuated by tax breaks for employers and workers.
They believe that consumers should instead get tax credits that they could use to shop for health insurance on their own.
Sen. John McCain of Arizona, the 2008 Republican presidential nominee, championed a similar proposal during his campaign. Ryan said in an interview that he hoped the proposal would be debated over the next year.
"The president's healthcare law kicks in in full force in 2014," he said. "And it's going to be very difficult to turn it off."
That could be the case even if the Supreme Court decides next year that the law's requirement for Americans to get health insurance is unconstitutional. A Republican president could write regulations without Congress that would dramatically weaken the law and make major changes to federal health programs such as the Medicaid program for the poor and disabled, according to liberal and conservative experts.
In the Senate, even a slim GOP majority could use budget reconciliation to eliminate hundreds of billions of dollars in spending needed to subsidize coverage for millions of Americans, a pillar of the law.
Budget reconciliation measures, which require only a simple majority, would prevent Democrats from filibustering the move. The tactic was used by Democrats to pass part of the law.
The bigger challenge confronting Republicans in 2013 may be political.
GOP proposals to scrap the employer-based healthcare system have never won wide public acceptance.
Even repeal could stoke a popular backlash. Although close to half of Americans say they oppose the new law, large majorities support key parts, including the guaranteed coverage, new aid to seniors on Medicare and assistance for low- and moderate-income Americans.
That has prompted some Republicans, including former Bush aide David Frum, to caution against a headlong rush to repeal.
In interviews, several GOP senators would not commit to using budget reconciliation. "The key is to try to do what is right and get things so they are under control," said Sen. Orrin G. Hatch of Utah.
Republicans will also have to contend with businesses — including some that give heavily to the party — that are wary of scrapping the law.
"Wholesale repeal leaves you with nothing," said Mary Grealy, president of the Healthcare Leadership Council, a leading coalition of healthcare industry executives.