In it, but not of it. TPM DC

Since Donald Trump stunned Washington and won the White House earlier this month, Republicans in Congress have been frantically dusting off their legislative wish lists and prepping for the new era in which their party is in the driver's seat.

For House Speaker Paul Ryan (R-WI), overhauling and privatizing Medicare – the popular, single-payer health insurance plan for senior citizens – is a top priority. What exactly the House's plan would look like remains unclear, as Republicans have just begun ruminating about overhauling Medicare. But there is a treasure trove of past Medicare ideas and blueprints from Ryan that give us insight into what his plan might look like.

Ryan has been pushing his privatization plan – or what he calls "premium support" – for years. It's been part of his annual budget blueprints, and it has evolved over time. The basic idea is that Ryan would give the elderly a set amount of money to buy health insurance rather than Medicare's fee-for-service system where the government pays doctors and hospitals based on the services they provide.

How much money the elderly would receive to buy insurance, the quality of the plans available, how the government would regulate them and the rate at which the benefits would increase have varied over the years and sometimes have been unclear.

As Medicare is currently configured, American workers and employers contribute equally to the public insurance program via the Medicare payroll tax. When people turn 65, they become eligible for Medicare's guaranteed coverage, pay premiums and receive a robust package of benefits.

Looming as the biggest unknown is whether Medicare – in its current form as a single-payer, guaranteed-coverage, fee-for-service system – will remain intact.

Will Medicare be eliminated explicitly, as it has in past Ryan plans? Will it be changed so substantially that the long-term effect will be to weaken it so that phasing out it out is inevitable? Or will Ryan seek to change Medicare in fundamental ways while still preserving its most important protections?

How committed President-elect Trump and Rep. Tom Price (R-GA), his nominee as secretary of Health and Human Services, are to Medicare privatization is another wild card in the mix.

"It is quite clear at this point that Ryan and Price would say they are retaining traditional Medicare as an option, but the question is under what terms. Is it provided under terms that would allow traditional Medicare to continue and flourish? Or is it conversely under terms that would cause it to wither and perish?" said Paul Van de Water, a senior fellow at the Center on Budget and Policy Priorities.

Over the years, Ryan's plans have evolved, in part because of pressure from his own members. Ryan told the New Yorker in 2012 that he recognized his plan needed to be accepted by more than just a few conservatives in the House. He needed to develop a plan that met the vision for the broader Republican conference.

He told the New Yorker in 2012, shortly before he became the Republican Party's vice presidential nominee, that his early plan "was just me, unplugged.”

"When you’re writing a budget you’re representing an entire conference, and so you have to get consensus," Ryan said.

But the underlying principle for Ryan's plans comes from the conservative idea that private businesses are more efficient at managing health care than the government would be. That, some experts argue just isn't true. Medicare, by and large, is a fairly efficient program. Seniors manage to get a lot of health care they are happy with for a decent price.

"Medicare is more efficient than private insurance for two main reasons. One it is able to pay providers less and second it also because of its size, it has lower administrative costs as well," Van de Water said.

Health care experts who have spent years analyzing Ryan's plans note that there are still a lot of questions to be answered. Here's what we do know:

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Republican senators are signaling that they shouldn't be tackling Medicare privatization anytime soon, at least not as part of repealing and replacing Obamacare.

The to do list for the Senate is already long. Senators are going to have Trump's cabinet to confirm, and they have to find a way to make good on Obamacare repeal and replace plan that many predict will take years. Add to it some motivation to tackle tax cuts and President-elect Trump's priority to pass a major infrastructure bill and suddenly overhauling traditional Medicare looks like a bridge too far, according to GOP senators who spoke with TPM.

Sen. Lamar Alexander (R-TN), chair of the Senate Health, Education, Labor and Pensions Committee, was blunt about the outlook for a major Medicare overhaul.

"I think we should leave Medicare for another day," he said. "Medicare has solvency problems. We need to address those, but trying to do that at the same time we deal with Obamacare falls in the category of biting off more than we can chew."

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The gravity of how difficult it will be to fully repeal and replace Obamacare is settling in on Capitol Hill.

Republican senators who spent years railing against the president's signature health care law are now trying to find consensus on how they want to make good on their years-long campaign promise to dismantle it – and the growing consensus is that it is going to take time to find a replacement.

"Its gonna take us awhile to make that transition from the repeal to actually replacing it with more affordable health coverage, which provides people better access," Sen. John Cornyn (R-TX), the Senate majority whip, told reporters Tuesday. "There is a lot to do so it's not going to happen overnight."

Republicans' inability to coalesce around a replacement plan in the six years after Obamacare was passed means they have no easy alternative to queue up with a repeal, which they have vowed to make the top of their agenda next year. Their current inability to settle on a clear repeal and replace plan also reflects the trade-offs that have been dogging the GOP in last half-decade. Within the Republican caucus are deep, philosophical rifts over basic questions about health care policy and the government's role in providing access to coverage.

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Incoming Senate Minority Leader Chuck Schumer (D-NY) said he welcomed a fight with Republicans over their attempts to privatize Medicare and signaled Democrats' plans to make it a major issue in confirmation hearings for Rep. Tom Price (R-GA), President-elect Donald Trump's pick for secretary of health and human services.

"Between this nomination, an avowed Medicare opponent, and Republicans here in Washington threatening to privatize Medicare, it's clear that Washington Republicans are plotting a war on seniors next year," Schumer said at a press conference Tuesday on Capitol Hill. "Every senior in America should hear this loudly and clearly: Democrats will not let them win that fight."

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Sen. David Perdue (R-GA) told reporters Tuesday that Republicans are eyeing a "partial repeal" of Obamacare and plan to keep some of the law's elements intact.

"It's a partial repeal first of all, it's not a total repeal," Perdue said. "Let's get that out of the way. It's a partial repeal, and I think there are pieces of it in there that have to stay in place for awhile and that is what we are going to be working on."

When asked which parts of the law, specifically, would stay, Perdue said "we'll get into the specifics of it in the next few days."

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Senate Judiciary Chair Chuck Grassley (R-IA) hopes to hold confirmation hearings for Donald Trump's pick for attorney general, Sen. Jeff Sessions (R-AL), before Trump's inauguration on Jan. 20.

Grassley's desire to expedite confirmation for Sessions, whose selection has prompted concern due to his hostility towards civil rights laws, was news to the senator who will be the top Democrat on the committee, Sen. Dianne Feinstein (D-CA), who told TPM Tuesday she was unaware of the plan.

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Those worried that Donald Trump would waffle on his promise to repeal Obamacare will find some of those concerns quelled with his nomination of Rep. Tom Price (R-GA) to be secretary of the Department of Health and Human Services. Price, a doctor who chairs the House Budget Committee, has been one of the most vocal critics of Obamacare and has offered multiple replacement plans over the years.

Just last month, he called the Affordable Care Act a “ridiculous” law with “failures” that “have been piling up.”

He promised a "a clean break with the past," including "a plan to repeal Obamacare and start over with real, patient-centered solutions – that puts patients and families and doctors in charge – not Washington DC."

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The video was chilling. Footage from a conference in Washington, D.C. over the weekend of the innocuously named National Policy Institute showed attendees thrusting their arms in the air in a Nazi salute as the man at the front of the room yelled “hail Trump, hail our people, hail victory!”

The Trump transition team responded with a vague statement about the white nationalist conference, distancing the President-elect broadly from racism. There was no specific denouncement of the meeting, however, or its leader, Richard Spencer, a young man who has spent the last few years laying the groundwork to modernize the white nationalist movement.

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A procedural step taken by the House GOP in its lawsuit targeting Obamacare is an early but revealing signal of the choices congressional Republicans and President-elect Donald Trump will face in repealing the Affordable Care Act.

House Republicans led by Speaker Paul Ryan filed a court document Monday evening asking an appeals court to pause the proceedings in the case, known as House v. Burwell. A senior GOP aide said the move was made to give the new administration the opportunity to weigh how to handle the lawsuit. What happens next (assuming the court grants Republicans the delay) could be an important indication of how the Trump administration and his congressional counterparts will work together moving forward on the larger repeal effort, and whether they are willing to wreak chaos on consumers in order to dismantle Obamacare.

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