WASHINGTON — Ben Sasse built his U.S. Senate campaign on the idea that he represented more than just another Republican vote against the Affordable Care Act.

Sasse and his supporters argued in 2014 that his background and expertise made him uniquely qualified to fight against the health care law.

The National Review crowned him “Obamacare’s Nebraska Nemesis,” predicting that Sasse “almost immediately would become one of the GOP’s most visible and articulate experts on the health care law’s defects and the ways to replace it.”

Since reaching the Senate more than two years ago, though, Sasse hasn’t offered his own plan to repeal and replace the health care law. He isn’t on any of the relevant committees that will draft a health care bill. In fact, he hasn’t even delivered any recent speeches devoted to the subject.

But Sasse said he isn’t backing off his signature campaign issue and continues to support a full repeal and replacement of the law.

He said his recent health care efforts have been behind the scenes — talking with colleagues about the best way forward now that the GOP controls both the White House and Congress.

“I’m trying to figure out how to add value, wherever I can, in that fight,” Sasse said.

He said he also has been working with the Trump administration. A source close to Sasse said the senator met with Vice President Mike Pence and Health and Human Services Secretary Tom Price last week to discuss health care legislation.

The health care stakes are higher for Sasse and other Republicans these days because their actions are likely to become law — and they will be held responsible for the consequences.

For years, GOP lawmakers voted repeatedly to repeal the Affordable Care Act, but they always knew that then-President Barack Obama would veto it. Now that Donald Trump has replaced Obama as president, they’re playing with live ammo.

Sasse said his fellow Senate Republicans are not as sure of their position on health care as they used to be. Some want only to repeal the current law; others suggest that it might be better to “fix” it than scrap it.

And those who want a full replacement plan are still struggling to agree on the details.

Last week, for example, House GOP leaders outlined a repeal-and-replace plan that would include health savings accounts, tax credits and state high-risk pools for the chronically sick. But they stopped short of giving specifics or explaining how they would enact legislation.

Meanwhile, Trump is talking about offering his own proposal, but he hasn’t done it yet.

John Hibbing, political science professor at the University of Nebraska-Lincoln, said Sasse and other Republicans have their work cut out for them trying to come up with a replacement plan.

“They’re all scratching their heads,” Hibbing said. “It was a lot easier to just rail about Obamacare.”

During the 2014 campaign, Sasse noted that he had read all 2,300 pages of the health care law and carried a copy of it on the campaign trail as a prop.

“Over the course of this campaign we plan to talk a great deal about patient-centered health policy solutions — for we want to wreck Obamacare, but then we also want to replace it with something that is actually workable, that actually benefits our neighbors,” Sasse said in announcing his campaign.

And indeed, Sasse highlighted efforts during his first two years in the Senate to make the case against the current law. For example, he pointed to the work he and aides did to identify declining competition among insurers at the county level.

The nonpartisan Kaiser Family Foundation now has started conducting its own county-level analysis of insurance competition.

“That kind of policy nerdy stuff that we did at the county level is now how they do it and how other people are doing it,” Sasse said.

Sasse pressed the Obama administration for answers over the failures of many of the law’s co-ops, at one point blocking all HHS nominees in order to force the release of information.

When the Supreme Court took up a challenge to the health care law in King v. Burwell, Sasse crafted a proposal for providing 18 months of alternative coverage for those affected if the court threw out the law. It was intended as a signal to the court that there were proposals in the hopper.

In the end, the court upheld the law. Still, Sasse said it shows that he was working to put forward actual solutions — and in a way that angered some opponents who wanted to simply let the whole thing collapse without any action by Congress.

After the Supreme Court decision, Sasse said he shifted his policy aides to focus on a successful effort to prevent any bailout of insurers as Obama left office.

And now he’s pushing to rally support for the full repeal-and-replace approach. There is a lot of internal struggle among Senate Republicans, with a slight but “fragile” trend toward his position, he said.

“There are some who would prefer to pivot back to a ‘fix it’ posture,” Sasse said. “I think that’s a really, really bad idea, and that’s what I’m fighting.”

With a bare majority of 52 Republican senators, only a few GOP defections could doom any health care legislation. As it stands now it’s unlikely that there are enough votes to repeal the health care law unless there’s a solid replacement plan in place. And yet there’s no consensus on the replacement plan either.

One area Republicans have struggled with is how to keep some of the popular elements of the Affordable Care Act, such as guaranteed coverage of those with pre-existing conditions, while dumping unpopular aspects, such as a requirement that individuals obtain health coverage.

”Right now what I think you see in the Republican conference is a lot of anxiety about admitting what your replace would look like, because there are a bunch of people who want to pretend you can have everything for nothing,” Sasse said. “You know — everything is going to be cheaper, everybody’s going to have full coverage for everything with low deductibles and low premiums and low out-of-pockets, and you’re going to have higher quality, lower cost instantly without (market innovation).”

Several key senators told The World-Herald they have discussed health care with Sasse, including Sen. John Barrasso, R-Wyo., who is the point person on health care among Senate leadership.

Most of the heavy lifting on health care will be done by the Senate Finance Committee and the Senate Health, Education, Labor and Pensions Committee. Sasse is not a member of either panel.

But Sen. Lamar Alexander, R-Tenn., who heads the health committee, said Sasse participates in GOP discussions on the topic and offers good advice.

“I’ve learned to pay close attention to Ben because he studies a lot,” Alexander said. “He doesn’t say too much, but when he says something, it’s worth listening to. And on this subject, he knows a lot.”

As for the timeline of repeal and replace?

“We’re waiting for the president’s plan, and then we’ll present our plan after that,” Alexander said.

Sen. Orrin Hatch, R-Utah, chairman of the Finance Committee, said he has had some chats with Sasse, but was more blunt about the overall legislative process on health care.

“It’s a big mess right now,” Hatch said.

While Sasse has not been giving speeches devoted to health care recently, he said he does get asked about it and is happy to share his thoughts. He also said it doesn’t make sense to introduce a full replacement proposal at this stage.

“I want to spend my time on stuff that’s actually going to make a difference,” he said. “Right now a full replace plan isn’t going to go anywhere until there’s enough votes for repeal.”

He said his vision for a replacement would track with the plan he outlined as part of his Senate campaign, intended to make health insurance more portable and flexible.

Those proposals hew to conservative health care approaches: Rather than mandating that individuals obtain coverage and that insurance companies sell policies to everyone, Sasse would give people more freedom to decide their level of coverage and rely more on their own money put aside in health savings accounts. States would craft programs to take care of those who can’t afford to buy their own coverage. Insurers could sell policies across state lines.

Sasse said he has worked on some components of a replacement plan, such as health savings accounts, trying to get equitable tax treatment between large employer group plans and individuals purchasing coverage. He said it doesn’t make sense strategically to spell out the details now.

“I’m for getting to tax equity,” he said. “I’m not for putting the particulars of what those threshold dollar amounts would be on the table, because then you don’t have anything left to negotiate from. You’re the opening bidder in a used-car sales purchase process.”

At the heart of the internal debate among Republicans, he said, is whether lawmakers are willing to admit that large employer group plans will need to change.

“A lot of politicians want to pretend that that’s not going to happen,” he said. “They want to tell people ‘Everything that you have, if you like it, you can keep it.’ ”

Meanwhile, conservatives eager to dump the Affordable Care Act are frustrated that Republicans aren’t charging forward, and Sasse said he also is impatient to get going.

While he is committed to a replacement plan and would prefer to pass it at the same time as repeal, Sasse said it’s not necessary to have the alternative in place before Congress votes to scrap the current law. The repeal effort could include a transition period that would protect those who rely on the law for coverage, he said, giving lawmakers time to come up with the replacement.

“I’ll do it today, I’ll do it tonight, I’ll do it tomorrow, I’ll do it tomorrow night,” he said. “I’m for repeal immediately.”

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Reporter - Politics/Washington D.C.

Joseph Morton is The World-Herald Washington Bureau Chief. Morton joined The World-Herald in 1999 and has been reporting from Washington for the newspaper since 2006. Follow him on Twitter @MortonOWH. Email:joseph.morton@owh.com

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