A Senate confirmation hearing on Tom Price, Donald Trump's pick to be the next U.S. Health and Human Services secretary, revealed more about the thinking of Senate Republicans who want to shore up the current commercial health insurance system while working on a replacement for the Affordable Care Act system.

The Senate Health, Education, Labor and Pensions Committee brought Price, a Republican representative from Georgia, in for a confirmation hearing Wednesday. As the head of HHS, Price would oversee Medicare, Medicaid, the Medicaid nursing home benefits program, and HHS ACA programs.

Democrats at the hearing probed Price, an orthopedic surgeon, about his investments, according to a video of the hearing posted on the committee website.

Several Republican senators at the hearing talked about efforts to make sure some kind of alternative to the Affordable Care Act is in place before repealing it or making major changes to ACA program funding levels.

The discussion was important because Republicans hold just 52 seats.

It's not clear how well old procedural rules and traditions will apply to the incoming Trump administration. If past procedural rules apply, ACA critics may need just 51 votes to get a measure de-funding major ACA programs, such as the ACA public exchange plan premium tax credit subsidy system, through the Senate. Republicans probably need 60 votes, including at least eight Democrats and independents, to get a bill that changes, fully repeals or fully replaces the ACA through the Senate.

Susan Collins of Maine and Dean Heller of Nevada have been especially vocal about the need for Republicans to have a ACA alternative in place when they pass ACA de-funding or repeal legislation.

Congressional Budget Office analysts recently added to pressure on Republican ACA opponents to work with Democrats to come up with an ACA repair or ACA replacement proposal that can attract 60 votes in the Senate, by predicting that a pure ACA de-funding measure would increase the number of uninsured people in the United States by 18 million in the first year after the de-funding took effect.

Trump has said several times that he wants to replace the ACA, not simply de-fund or repeal it.

Sen. Lamar Alexander, R-Tenn., the chairman of the Senate HELP Committee, represents a state that's home to HCA Inc., a giant Nashville-based hospital company that has benefited greatly from the ACA Medicaid expansion program.

Alexander said at the hearing that replacing the ACA, which he calls "Obamacare," is like replacing a bridge that's near collapse.

A bridge past the ACA

If the ACA were a bridge, "the first thing we would do is send in a rescue crew to repair the bridge temporarily, so no one else is hurt," Alexander said. "Then we would build a better bridge."

Once Republicans build a "better health care bridge," they would probably replace the ACA with efforts to return authority to the local level and a variety of small bills, not a wheelbarrow containing a "4,000-page comprehensive health care plan," Alexander said.

After the federal government eases away from the ACA system, then it can repeal the ACA, Alexander said.

Collins said she thinks the Congress needs to pull the plug on the ACA, but the Congress needs to have an alternative in place quickly, to avoid pulling the rug out from under people.

Price told Alexander that he thinks ACA efforts should focus mainly on the individual and Medicaid markets, not Medicare.

Price also seemed to hint at providing transitional arrangements. "We believe it is absolutely imperative that individuals that have health coverage be able to keep health coverage and move hopefully to greater choices," he said. "There has been a lot of talk about individuals losing health coverage. That is not our goal, nor is it our desire, nor is it our plan."

In response to a suggestion by Alexander that health insurers might need to see a plan for 2018 in place by March 1, so they can plan for 2018, Price did not give a clear answer. He did say that looks forward to using the Senate budget measure process, which lets measures to get through the Senate with 51 votes, to "address the real challenges in the Affordable Care Act, and to make certain we put into place at the same time a provision that allows us to move the health care system in a much better direction."

One point that's clear is that Price is not a fan of trying to improve the health care system by increasing patients' out-of-pocket costs.

"I get calls almost weekly from my former fellow physicians, who say their patients are making decisions about not getting the care that they need because they can't afford the deductible," Price said. "If you are an individual making $40,000 or $50,000 per year, and your deductible is $6,000 for a family, which is not unusual, your insurance card might be wonderful, but you can't have any care, because you can't afford the deductible."

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