Conservatives who have been dissatisfied with the Obamacare repeal and replacement bill put forward by House leadership this week are mobilizing around making a major change to how the legislation handles the Affordable Care Act’s Medicaid expansion.
The topic came up in a Wednesday meeting between the leaders conservative organization and President Trump, and by Thursday morning, an influential group of conservative House members endorsed speeding up the process by which the GOP bill would wind down the expansion.
The changes would please hardline conservatives in the House Freedom Caucus, who have introduced their own bill to strip away the Medicaid expansion over two years, but it would alienate moderate Republicans whose states have expanded Medicaid under the Affordable Care Act to cover millions of low-income residents.
With the fate of the GOP bill to repeal the Affordable Care Act in jeopardy, Trump huddled Wednesday night with outside conservative groups—including the Koch brothers’ Americans for Prosperity, the Heritage Foundation and the Tea Party Patriots—to debate the most sensitive and divisive questions surrounding the health care overhaul.
In that meeting, the president heard the concerns from the conservative members that Medicaid expansion was being allowed to continue under the leading House GOP health care overhaul bill, and he was reportedly open to negotiating around their demands.
Changes to the Medicaid expansion provision in the current House leadership legislation were one of a number of ideas floated between the conservative leaders and Trump, people in the room told Politico. FreedomWorks President Adam Brandon confirmed with TPM Thursday morning that the tropic came up and White House officials heard their frustrations with how the Medicaid expansion was treated in the House leadership’s Obamacare replacement, the American Health Care Act.
“They wanted to understand what our concerns were,” Brandon said, adding that specifics of proposals to address those concerns were not discussed.
The GOP hardliners are objecting to the way the AHCA allows states to keep their Medicaid expansion operating as is until 2020 and would even allow others states to opt in. At that point, enrollment on the Medicaid expansion program would freeze and anyone who lapses in eligibility would not be able to re-enroll. The idea is that the program would wither away on its own, but in the meantime expansion states would keep the generous match rate as Medicaid as a whole is turned into a block grant in the form of per capita cap.
“I’m not in favor of the expansion. If states want to do expansion, that’s fine,” Rep. David Brat (R-VA) told reporters on Capitol Hill Wednesday. “I’m not against giving them a big chunk to help them transition, to take care of preexisting conditions, to not pull the rug out from under anybody. But get the feds out of it.”
Also on Wednesday, a conservative Energy and Commerce Committee member, Rep. Joe Barton (R-TX), introduced amendments to the health bill during the committee’s ongoing mark-up of the legislation that would move up the freeze of Medicaid expansion and put a hard end date on the generous match rate that the federal government provides for the program.
As of press time, potential changes to the bill’s Medicaid expansions provisions were still being discussed in the ongoing committee hearing, which started Wednesday morning and ran through the night.
The amendments got a major boost of support Thursday morning when the Republican Study Committee — a group comprising 170 or so members and whose chair Rep. Mark Walker (R-NC) has been critical of the leadership bill — endorsed Barton’s amendment to freeze the expansion by the end of 2017. They also endorsed an amendment that would impose work requirements on able-bodied, childless adults on Medicaid.
“While I continue to have concerns about this bill, the adoption of these amendments would be a critical step in the right direction,” Walker said in a statement.
But the problem for Republican leadership is that conceding to conservatives’ demand on Medicare expansion risks losing the votes of moderates, particularly in the Senate, where the GOP can spare a mere two votes. Earlier this week, four Republican Senators who hail from Medicaid expansion states signed a letter that warned against “any poorly implemented or poorly timed change in the current funding structure in Medicaid could result in a reduction in access to life-saving health care services.”
Some House Republicans have also expressed concerns regarding a rapid phase-out of the Medicaid expansion.
“I think you have to give states the time to address it,” Rep. Robert Pittinger (R-NC) told TPM on Wednesday. “You can’t just snap it away.”