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Tierney Sneed

Tierney Sneed is a reporter for Talking Points Memo. She previously worked for U.S. News and World Report. She grew up in Florida and attended Georgetown University.

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House Speaker Paul Ryan (R-WI) argued Thursday that moderate Republicans wavering on supporting the latest iteration of the GOP’s Obamacare repeal bill would be more likely to lose their seats if they voted against the legislation.

“I think people’s seats are at risk if we don’t do what we said we would do. We all campaigned on repealing and replacing this law that is collapsing,” Ryan said at a Thursday press conference, when asked about moderates nervous they would lose re-elections if they voted for the unpopular bill.

“We promised that we would do this,” Ryan said. “If you violate your promise, if you commit the sin of hypocrisy in politics, that’s the greater risk, I think, to a person’s seat.”

Ryan’s comments represent a ramping up of a pressure campaign on moderates to fall in line with the bill, the American Health Care Act, now that a recently agreed upon amendment has gotten the backing of the conservative faction that was resisting the legislation. The legislation would massively cut Medicaid and make the tax credit scheme for individual insurance plans less generous for older people. The new provisions would also allow states to apply for waivers to opt out of certain Affordable Care Act insurer mandates in a way that would essentially gut pre-existing conditions protections.

Ryan argued Thursday that the bill’s funding for high-risk pools and various types of re-insurance programs, as well as the stipulations it places on states applying for waivers, offer more protections for those with pre-existing conditions than current law.

Nonetheless, the moderates who were opposed to the original bill, and even some who intended to vote for it before it was pulled from the floor last month, have been skeptical about the latest changes. There have reportedly been frustrations among members of the moderate Tuesday Group that the group’s co-chair Tom MacArthur negotiated the latest changes with hardline conservatives .

Ryan, on Thursday, denied these frustrations existed and pointed to MacArthur as a reason moderates should vote for the bill.

“Tom MacArthur is the leading moderate in Congress. It’s his amendment,” Ryan said.

A top House Democrats threatened a possible government shutdown if Republicans scheduled a quick vote for their Obamacare repeal bill.

“If Republicans announce their intention to bring their harmful TrumpCare bill to the House Floor tomorrow or Saturday, I will oppose a one-week Continuing Resolution and will advise House Democrats to oppose it as well,” House Minority Whip Steny Hoyer (D-MD) said in a statement Thursday.

The threat comes has rumors have circulated that Republicans are hopeful for a vote this weekend, in time for President Trump’s 100th day in office, on their recently revived health care overhaul bill, the American Health Care Act. In the meantime, Congress will need to pass a short-term funding bill by Friday to avert a government shutdown and give them a few more days to pass a longterm spending measure.

Trump appeared to respond to Hoyer’s threats in a tweet that referenced a provision in the short-term bill protecting miners’ health benefits.

It’s unclear if GOP House leaders have the votes to bring the health care bill to the floor soon. The conservatives previously resistant to the legislation have come around after a new amendment was unveiled this week, but moderates who opposed the bill remain skeptical.

Alice Ollstein contributed reporting.

After being steamrolled in the negotiations surrounding Obamacare repeal, House Republican moderates appear poised to be run over once more—and perhaps, a final time—as momentum grows behind a revived version of the repeal bill.

Their rival faction, the House Freedom Caucus, has backed the newest form of the legislation having received another round of concessions. That means the pressure is on the conference’s centrist wing to fall in line, despite having gained little throughout the negotiation process.

Moderates who have been steadfastly opposed to the direction things were headed with the bill, the American Health Care Act, remained skeptical of the true purpose of the latest round of deal-making. The GOP centrists who were previously supportive or undecided are clamoring for more time to understand the new changes to the bill and what they mean for the legislation or even for their political careers.

“I’ve often felt that a lot of this has been simply an exercise in blame-shifting, because we know that this bill, in its current form, with or without the amendment, will be gutted in the Senate,” Tuesday Group co-chair Charlie Dent (R-PA), a consistent “no” vote on AHCA, told reporters Wednesday. “So this is simply a matter of blame shifting and face saving.”

Rep. Mario Diaz-Balart (R-FL) (pictured above), a yes vote on the original legislation, said Wednesday he was withholding “judgment” on the new changes until he studied them further.

“I’ve got to look at the impacts and see what it does,” he said.

The original bill would have cost 24 million people their health care coverage over the next 10 years, according to estimates by the CBO. It would begin scaling back Medicaid expansion in less than two years (a loss for the moderates who hail from expansion states) while making major cuts to the broader Medicaid program over time. It shifted the ACA’s tax credits in a way that benefited young people while short-changing older consumers, another element moderates were uncomfortable with. These cuts pave the way for the elimination of many of Obamacare’s taxes, mainly for the industry and high-income earners.

All those provisions remain in the new version of the bill, but instead an old provision that would have gutted the ACA’s essential health benefits is now optional for states to waive into.

The latest changes, hammered out by Freedom Caucus Chair Mark Meadows (R-NC), and one of the moderates’ own, Tuesday Group co-chair Tom MacArthur (R-NJ), allows states to opt out of ACA insurer mandates in a way that would essentially gut its pre-existing conditions protections, the Holy Grail of the promises many Republicans made about their replacement.

“I spent the whole work period hearing from people pissed about pre-existing conditions,” one moderate lawmaker told CNN on Wednesday. “This isn’t helpful.”

Another moderate was overheard by the Hill telling a staffer: “If I vote for this healthcare bill it will be the end of my career.”

Moderates got almost nothing in return in this new “compromise,” and were already uncomfortable with the legislations massive cuts to Medicaid and how it structured tax credits for individual insurance. Many centrists who are still weighing whether to vote for the bill admit that it’s only been pulled to the right since the original legislation was pulled from the floor.

“There’s been some moving of the goal posts that have been concerning to a lot of us,” moderate Rep. Tom Reed (R-NY) told reporters Wednesday, adding that in general he is in favor of more control for the states. A previous yes vote, he described himself as a lean yes while he looked over the latest changes.

The pressure is amping on them to hold their nose, with White House officials telling the press they’d like to hold a vote as early as this weekend.

“I think anybody who is wavering feels some pressure because the vast majority of our conference wants to pass this bill,” MacArthur told reporters Wednesday, according to CNN.

It’s unclear how many moderate votes GOP leadership will need to flip to yes on the bill to make it passable.

“You might be able to get there without them,” said Rep. Tom Cole (R-OK), a leadership ally who is not a moderate and has been supportive of the bill. “But look, we want something that everybody feels comfortable voting for. Our leadership is certainly not trying to deal anyone out of the game.”

The Freedom Caucus was widely blamed for the failure of the original bill, but the morning that it was pulled, it was the last minute statements of oppositions from non-Freedom Caucus Members, such as House Appropriations Chair Rodney Frelinghuysen (R-NJ) and moderate Rep. Barbara Comstock (R-VA), that felt like the death knell. Since many moderates were still publicly unclear or undecided, it’s unknown exactly how many votes GOP leadership had been deprived from the moderate wing in order to mount them to 216 votes.

Office of Management and Budget Director Mick Mulvaney said earlier this month that the White House’s internal whip count showed that moderates made up about half of the 36 votes against the original AHCA.

When all is said and done, the White House can only afford to lose 22 votes total and still pass the bill. Ten or 11 moderates so far, according to various outlets’ whip counts, have already came out against the new version and dozens more remain unclear.

Amidst all this is frustration that MacArthur worked with the conservative hardliners in the first place. At Wednesday’s Tuesday Group meeting after the new changes were unveiled, some members vented their frustrations with MacArthur for putting them in this position, two aides told the Hill. Dent told reporters after the meeting that members of the Tuesday Group had previously communicated to all the co-chairs that they’d prefer the negotiations be left to those on the relevant committees.

“Many of the members of the Tuesday Group made it very clear to me that they didn’t want me or anyone else negotiating,” Dent said.

A major impasse to Congress coming to a deal to keep the government funded past Friday was overcome on Wednesday, with signals from the White House that it would continue to pay Obamacare subsidies that Democrats wanted explicitly guaranteed in the funding legislation being negotiated. Earlier in the day, House Speaker Paul Ryan said appropriating the payments wouldn’t be in the funding bill.

Democratic leaders issued statements Wednesday afternoon that seemed to confirm reports that the White House had offered assurances to lawmakers that the payments would continue, at least in the short-term, despite President Trump’s previous suggestions that he would use them as leverage to force Democrats to negotiate on dismantling the Affordable Care Act.

“It is good that once again the president seems to be backing off his threat to hold health care and government funding hostage,” Senate Minority Leader Chuck Schumer (D-NY)  said in a statement, adding that there other issues still being resolved in the government funding negotiations.

“I am pleased that the White House confirmed what I’ve been asking for: that they will uphold their commitment under the law to continue making cost sharing reduction payments,” House Minority Whip Steny Hoyer (D-MD) said in his own statement.

House Republicans sued the Obama administration in 2014 over the subsidies, which were being made out of the Treasury Department, alleging they were illegal because they were not explicitly appropriated by Congress. A federal judge agreed last year but allowed them to continue while her decision in favor of the Republicans was appealed by the Obama administration.

The payments became a flashpoint in the current government funding battle after Trump, earlier this month, speculated that if he withheld the payments Democrats would come to the table on replacing Obamacare. Dems responded by making the payments a priority in their funding negotiations, though this week some Democrats were waffling on whether they would shut down the government over them.

The payments subsidize insurers for keeping out-of-pocket costs down for low-income consumers, as mandated by the ACA. If eliminated, it’s anticipated that insurers would be forced to jack up premiums to make up the revenue shortfall or withdraw from ACA exchanges entirely, risking a collapse of the individual market.

Even though the government funding crisis over the payments appears to have been averted, that still doesn’t answer questions about their longterm fate, specifically where the lawsuit is concerned.

Since Trump was elected, it has been unclear whether the Justice Department under his administration was going to continue to defend them, and a pause on the legal proceedings was granted by the appeals court until May for the parties to figure out their next move.

Hoyer, in his statement, pointed to the current legal uncertainty and argued that it was now “incumbent upon House Republicans to withdraw their lawsuit that seeks to block these payments.”

A top insurer group echoed his desire for a more action to be taken on cementing their longterm fate.

“We continue to need clarity,” Kristine Grow, a spokeswoman for America’s Health Insurance Plans, said in an email to TPM in response to the Dems’ statements.

Meanwhile, some Republicans pointed to the legal case as reason for the White House not to continue the subsidies.

“The Constitution provides that ‘No money may be drawn from the Treasury, but in consequence of Appropriations made by Law.’ Congress has made no appropriation for Obamacare cost sharing reduction payments,” Rep. Mark Walker (R-NC), chairman of the Republican Study Committee, said in a statement. “Therefore, we believe making these payments without congressional approval is both clearly illegal and unconstitutional, as the district court held in House v. Price.”

 

Alice Ollstein contributed reporting.

Not long after conservative hardliners in the House signaled they would be supporting a new version of the GOP’s failed Obamacare repeal bill, the group of the conference’s moderates known as the Tuesday Group emerged from a meeting Wednesday skeptical of the proposed changes to the legislation, which would allow states to essentially gut the Affordable Care Act’s pre-existing conditions protections.

Many moderates, including those who were previous “yes” votes on the original bill, as well as those who had come out against it, said they would need to see more information about the proposed amendment. More concerning for Republicans hopeful for a deal on Obamacare repeal, some former “yes” votes said that they were now undecided on the larger legislation due to the changes.

“There’s a lot of uncertainty. Most people don’t understand exactly what’s in the legislation,” Rep. Carlos Curbelo (R-FL) told reporters. “We need an analysis, we need an explanation of how this is all going to work.”

The amendment was worked out between Tuesday Group co-chair Rep. Tom MacArthur (R-NJ), who was supportive of the original bill, and Freedom Caucus Chair Mark Meadows (R-NC), who had led the conservative opposition to the previous iterations of the legislation. The proposal would allow states to opt out of certain  Affordable Care Act mandates on insurers, with some mandates able to be waived only if specific conditions were met.

The concession for moderates was that the ACA’s Essential Health Benefits requirement—which mandates 10 broad coverage areas insurers must offer—was no longer fully gutted as it was in the original bill but rather optional for states. However, at least a dozen moderates opposed the original bill for other reasons, like how it structured its tax credits for insurance or how drastically it scaled back Medicaid. Those issues weren’t addressed in the new deal.

“Too many people have viewed this health care reform process as a speed bump on the road to tax reform,’ said Rep. Charlie Dent (R-PA), a co-chair of the Tuesday Group who opposed the original bill and the new changes as well.

Dent said that no whip count had been conducted in the Tuesday Group meeting, but it was his sense that the moderates who were “no’s” before remained no.

Other previous “no” votes, such as Rep. Leonard Lance (R-NJ) and Rep. Dan Donovan (R-NY) said their positions remained unchanged Wednesday.

Rep. Barbara Comstock (R-VA), who came out against the original bill before it was pulled from the floor, said that she did not have “adequate” information yet to say whether the amendment would change her vote.

Rep. Mike Coffman (R-CO) (pictured) said he was previously yes on the bill but now considers himself undecided with the new changes.

“With the prior bill, I supported that publicly before it went down. This is a different twist and I have got to re-examine it,” he said.

The House Freedom Caucus announced Wednesday that its was supportive of the amended health care bill—meaning that at least 80 percent of its 40-or-so members were likely to vote for it—as outside conservative groups withdrew their opposition to the legislation given the proposed changes.

Asked about the pressure now on the moderates to fall in line, Dent said, “I can deal with pressure any way it comes.”

As Congress nears a funding deal to avert a government shutdown later this week, House Paul Speaker (R-WI) said Wednesday that explicit appropriations for crucial Obamacare subsidies to insurers would not be included.

“Obviously CSRs — we’re not doing that,” Ryan said, referencing the payments known as cost-sharing reduction subsidies. “That is not in an appropriation bill, that’s something separate that the administration does.”

The fate of the subsidies, which are currently paid by the Treasury Department, is unclear as they are the target of a House GOP lawsuit and ending them has been floated by President Trump as a potential bargaining chip as he seeks to repeal the Affordable Care Act. If the subsidies were halted, it’s anticipated that insurers would jack up premiums to make for the revenue shortfall or leave the individual market entirely.

While Ryan suggested that the administration would just continue making the payments, there has been confusion over whether the White House had really made that assurance.

A Democratic aide said that Office of Management and Budget Director Mick Mulvaney told House Minority Leader Nancy Pelosi (D-CA) Tuesday night that administration was considering not making next month’s payments and just allowing a federal court ruling against the payments to stand, according to reports in the Washington Postthe Hill and Vox. Pelosi had been stressing to Mulvaney Democrats’ desire to to see the payments included in the spending bill, according to the reports. A White House aide disputed the account somewhat to the Hill and Vox, by clarifying that the administration was still making up its mind on its next steps.

“The 11th hour is not the time nor the place for that discussion,” an OMB official told Vox, stopping short of guaranteeing the payments would continue.

The lack of clarity is making insurers, providers and patient advocates extremely antsy.

The subsidies go to insurers so they can keep out-of-pocket costs down for low income consumers, as mandated by the Affordable Care Act. House Republicans challenged the payments in 2014 under the Obama administration, arguing that Congress had not appropriated the funds for the subsidies. They won a ruling against the payments from a district court judge last year. The Obama administration appealed the ruling and the payments have been allowed to continue while the case proceeded. After Trump was elected, the appeals court now overseeing it allowed the proceedings to be paused while his administration and the House GOP work out their next steps.  They will need to update the court in May, around the time insurers will be making their decisions whether to participate in ACA exchanges in the 2018 plan year.

Trump, meanwhile, suggested earlier this month that he would use the payments as leverage to get Democrats to negotiate on Obamacare repeal, prompting Dems to ramp up their calls for the payments to be appropriated. Insurers would prefer the payments be included in congressional spending legislation, rather than simply continued by the administration.

 

House Republicans seemed optimistic Wednesday morning coming out of their conference meeting— their first, full-conference gathering since their two-week recess—about the prospect of reviving their Obamacare repeal push with a new agreement between one prominent moderate and a leader of the hard-right faction of the House. Whether the deal actually secures enough votes to make the GOP’s failed health care legislation, the American Health Care Act, passable out of the lower chamber is still very much an open question

The new amendment proposed for the bill appears to have stirred some movement among skeptical conservatives towards favoring the bill. At the same time, some moderates who had been uncomfortable with the original legislation were reticent to say Wednesday whether the new proposal would out them solidly in the “yes” column. Other centrists and rank-and-file members previously supportive of AHCA were hopeful that the new proposal would hit the sweet spot in securing the 216 votes needed to pass the repeal, while leadership kept expectations down.

“It helps us get to consensus,” Speaker Paul Ryan (R-WI) said at a press conference after the morning meeting.

The new proposal was crafted by moderate Tuesday Group co-chair Rep. Tom MacArthur (R-NJ) and House Freedom Caucus Chair Mark Meadows (R-NC) over the recess, with the involvement of  Trump administration officials. It allows states to apply for waivers from certain insurer mandates under Obamacare.

So far, conservatives seemed most excited about that changes.

Rep. David Brat (R-VA), a vocal critic of previous iterations of the health care bill, said the proposal made him a yes on the legislation, because it gives states the “ability opt out of regs to lower prices.”

“I think it’s a step in the right direction,” Scott DesJarlais (R-TN), a member of the Freedom Caucus who had wavered on supporting the original bill, told reporters Wednesday.

Additionally some influential conservative groups who had opposed previous versions of the bill issued statements of support of the new changes. The Freedom Caucus will meet Wednesday evening to further discuss the proposal.

Moderates have been less eager to share how the proposal affected their votes.

Rep. Barbara Comstock (R-VA), who came out against the original bill before it was pulled from the floor, told reporters while heading into the meeting that she hadn’t had a chance to look at the new language. Coming out of the conference meeting, Rep. Ryan Costello (R-PA) said that he was not a firm yes or no yet.

“The concerns are what they have always have been, and I’ll have to look at what the amendment does, what the implications may be,” Costello, who was undecided on the original bill, told reporters.

Rep. Charlie Dent (R-PA), who co-chairs the Tuesday Group, said Tuesday he was still opposed to the bill, as did Rep. Leonard Lance (R-NJ).

Nonetheless, Rep. Kevin Cramer (R-ND) told reporters that he believed the new proposal found a “sweet spot” for moderates by bringing back essential health benefits, an ACA mandate that was gutted by the original bill, but giving the states the option to waive them.

“I think it could be a sweet spot that attracts enough people to get us to a majority,” Cramer said.

According to the moderate Rep. Chris Collins (R-NY), a Trump ally who was supportive of the original bill, members at the conference meeting were told that the whip team would start reaching out to previous “no” and “lean no” votes to see if their votes had changed with the amendment. Those who were “yes’s” on the original bill would be assumed to be still be supportive, Collins said, unless they approached leadership to tell them that the new proposal had changed their vote.

“There is no definitive timeline” on bringing it to a floor vote, Collins said, pointing to the need to pass a government funding bill this week.

“Everyone would like to do it sooner than later, many of us would like to do it this week. The Speaker was clear: we will bring it to the floor when we have the votes to pass it,” Collins said.

The new proposal, according to legislative text leaked by Politico, is similar to what was being floated before recess and would allow states to waive out of certain Affordable Care Act insurer mandates.

The first waiver, which would be available to states in 2018, would allow states to extend the so-called age band—which sets the maximum premium ratio between a plan’s youngest and oldest consumer—from its current three-to-one limit. (It’s unclear how this interacts with the previous version of the repeal bill, which already extended the ratio to five-to-one).

The second waiver would let states rewrite and scale back the ACA’s essential health benefits, the 10 coverage areas insurers are now currently required to offer. That waiver would be available in 2020.

The third type of waiver applies to the ACA’s so-called community ratings, which currently restrict insurers underwriting based on health and other factors. Under the proposal, states could permit insurers to engage in some underwriting, specifically based on one’s health’s status, if the state participated in some sort of high risk pool, reinsurance or risk sharing program. The proposal also stipulates that those who maintain continuous coverage would not be subject to that kind of underwriting.

In their waiver applications to the Health and Human Services Department, states would have to describe how their request would help the state one of a few goals, such as lowing average premiums or increasing coverage. If HHS doesn’t respond in 60 days, the waiver would automatically be granted.

“Essentially, any state that wanted a waiver would get one,” Timothy Jost, a health law specialist at Washington an Lee, wrote on Health Affairs blog Tuesday night.

Given the opportunity to drop its defense of Obamacare’s contraceptive mandate in a case challenging its accommodation to religious employers, the Justice Department, under President Trump, asked the court for more time Monday to consider the “complex” issues within a Supreme Court directive handed down last year in a related lawsuit.

The move upset those challenging the accommodation, the Washington Post reported, who believe the Trump administration is violating his campaign promise to reverse the Justice Department’s defense of the waiver option the federal government offers organizations with religious objections to the contraceptive mandate.

“That just seems to be very contrary to what they’ve been saying publicly,” Eric Rassbach—a lawyer working for the religious freedom legal firm that is representing some of the challengers—told the Washington Post about Monday’s filing.

The case, East Texas Baptist University v. Price, is a consolidation of multiple lawsuits against the Health and Human Services Department and other federal agencies brought by employers who object to the accommodation granted to religious organizations that don’t want to cover birth control, as mandated by the Affordable Care Act. The groups say that even filling out the form asking to opt-out of covering the contraceptives—and thus triggering the process through which their employees receive the coverage elsewhere—is a form of complicity in forms of birth control to which they have religious objections.

One such legal challenge, Zubik v. Burwell, made it up to the Supreme Court last year.  The court, down to eight members after the death of Justice Antonin Scalia, essentially punted and asked the parties to figure out a compromise. Those negotiations are currently going on at the appeals court level, including at the U.S. Court of Appeals for the 5th Circuit, where the East Texas Baptist University case had been paused for the parties to hash out a potential agreement.

Last week, some of the religious groups had asked for the 5th Circuit to end its pause on the proceedings and for the Justice Department to drop its defense of the accommodation:

It has been more than eleven months since the Supreme Court vacated and remanded this appeal to this Court. During that interval, there has been a presidential election, a new President inaugurated, both a new Attorney General and a new Secretary of Health and Human Services sworn in, and a new Supreme Court Justice confirmed by the Senate. There have also been four orders issued by this Court continuing the stay of this appeal, No. 14- 20112. The government’s position in this case has also changed dramatically—both before and after the events described above—in ways that make any continuation of the government’s appeal untenable. It is now high time for the Department of Justice to admit defeat and dismiss this appeal. This Court should therefore allow the current stay to expire as scheduled on April 24.

The Trump administration, however, asked for the pause on the proceedings to continue in its filing Monday:

Plaintiffs emphasize that eleven months have elapsed since that remand order but, as they acknowledge, the new Administration has been in place for only a few months. The regulations at issue here are jointly administered by three Departments—the Department of Health & Human Services, the Department of Labor, and the Department of the Treasury—and are the subject of numerous other lawsuits being handled by the Department of Justice. The nominee to be Secretary of Labor has not yet been confirmed, and numerous subcabinet positions at the Departments have not yet been filled. The issues presented by the Supreme Court’s remand order are complex; for example, the original accommodation took more than a year to develop with input from interested parties.

Read the full Trump administration filing below:

If President Trump makes good on his threat to halt $10 billion in Obamacare subsidies to insurers in 2018, known as cost-sharing reduction payments, the federal government would spend a net $2.3 billion more due to anticipated premium hikes, a Kaiser Family Foundation study has found.

“We estimate that the increased cost to the federal government of higher premium tax credits would actually be 23% more than the savings from eliminating cost-sharing reduction payments,”  the study, released Tuesday, said.

The cost-sharing reduction payments subsidize insurers for keeping out-of-pocket costs down for low income consumers, as mandated by the Affordable Care Act. They were the target of a House GOP lawsuit launched against the Obama administration in 2014 which alleged the payments are illegal because they were not explicitly appropriated by Congress. A federal judge agreed, but allowed the payments to continue while the case is appealed. The proceedings are currently paused as the Trump administration and the House Republicans figure out their next moves. But insurers and other health care industry stakeholders are getting increasingly vocal in their calls for some sort of clarification on the long-term fate of the payments, which 7 million consumers benefit from.

It’s estimated that ending the payments would prompt insurers to jack up premiums by 19 percent to recoup the lost revenue or exit the individual market altogether.

Because, under Obamacare, the federal government also offers subsidies to consumers between 100-400 percent of the poverty line for their individual premiums, and those subsidy levels rise and fall with the average premium for a certain plan, much of that increase in premiums would be picked up by the government. (The cost-sharing subsidies, meanwhile, benefit those making 100-250 percent of the federal poverty line).

Kaiser estimated that when extended out to the 10 year budget window, the feds would end up spending $31 billion more on the individual premium hikes than what the government would save by ending the CSR payments.

Trump has floated ending the payments as a way of forcing Democrats to negotiate on an Obamacare repeal measure, which has faltered in the House. Congressional Dems are now seeking to have the payments permanently funded as part of the broader government spending package being hashed to avoid a government shutdown at the end of the week.

Republicans just can’t quit Obamacare repeal.

Even as they face an insanely busy week when a government shutdown will need to be averted and President Trump would also like to unveil a tax overhaul plan, some GOP lawmakers—perhaps at the behest of White House officials seeking to save face ahead of the 100-day mark—are talking up the possibility of a new deal to revive legislation to dismantle the Affordable Care Act.

Even as GOP congressional leaders tamp down expectations of any quick movement to resuscitate the bill, which was pulled from a House floor vote last month due to lack of support, the latest round of hype signals a longer-term problem for the GOP’s approach to governance. As long as Republicans can’t fully move on from Obamacare repeal, it stands to infect the other agenda items they seek to pass while they still have full control of Congress.

“The bills is undead. You can’t kill it, you can’t revive it,’ said Jonathan Oberlander, a professor of social medicine and health policy at the University of North Carolina-Chapel Hill.

This week, for instance, a potential government funding showdown has shaped up around threats from Trump to blow up the ACA’s individual market unless legislators fund his border wall, a political flashpoint that neither Democrats nor many Republicans want to hash out in must-pass spending legislation.

Trump’s apparent logic is that such tactics give him leverage to force Democratic negotiations on repealing Obamacare—a posture that doesn’t really make sense when grounded in both the political realities of who owns health care at this point (Republicans) and the GOP’s own moves to shut Democrats out of their legislative process.

More broadly, Obamacare repeal presents a confluence of conditions that risk trapping Republicans in a “zombie-care” political quagmire. On the one hand, they’ve made Obamacare repeal a central campaign promise for seven years and put it on the top of their legislative agenda. On the other hand, congressional leaders put the repeal effort on an expedited time-line, giving themselves only a few weeks to cobble together a bill and shore up conference-wide support for a quick passage that would make way for tax reform.

Topping it all off, Republicans are being led in this endeavor by a President with little interest in the mechanics of health policy, little knowledge of the sausage-making of the legislative process, and a penchant for a made-for-TV style of negotiating.

“Why they’re saying that they’re going to keep doing it is because it’s incredibly important, because they staked a lot of political capital on repeal and replace during the election,” Caroline Pearson, senior vice president at the health care consultancy Avalere Health, told TPM.

As a GOP leadership aide told Axios recently, “It’s hard to imagine not resolving the health care issue at this point. We are too far along to abandon the effort altogether.”

In reality, they did not actually get very far: Republicans gave themselves only a few weeks between unveiling the legislation and slating it for a floor vote, and in the process, held just a handful of hearings. They have basically no buy-in from outside stakeholders: the reaction to the legislation from major hospital groups, patient advocates and insurers ranged from muted expressions of concern to, more commonly, vehement opposition.

The latest flicker of hope comes from a deal reportedly offered by Rep. Tom MacArthur (R-NJ), who co-chairs the moderate Tuesday Group, to let states waive certain ACA insurer mandates. The rumblings began in the middle of last week, with White House officials optimistic that the bill could be brought up for a vote again this week, despite all the other matters lawmakers have on their plates.

Still, the fundamentals, in terms of counting votes, have yet to visibly shift. Speaker Paul Ryan (R-WI) told GOP lawmakers during an “all-hands” conference call Saturday that no votes would be scheduled until it was clear the bill had the votes to pass, the Washington Examiner reported, and there are no signs yet of an aggressive whip operation.

What Trump has created for congressional Republicans is an atmosphere where moderates are being slammed by their constituents for supporting the failed bill, conservative hardliners are doubling down on their demands for a more sweeping repeal of the law, and no one wants to be the one blamed for its failure.

“They sold the original bill short and now they’re having regrets about that but they’re having trouble coming up with a better deal than they had to begin with,” said Tom Miller, a health care policy expert at the conservative American Enterprise Institute.

Trump, meanwhile has tossed off public threat after public threat, including the elimination of Obamacare subsidies that, if halted, would lead to major chaos to the insurance industry. Funding the payments, known as cost sharing reduction subsidies, has now become a flashpoint for government spending negotiations.

“This works within a 24 hour cable news cycle. It doesn’t play out on the legislative front,” Miller said. “It’s not just a soap opera or a momentary headline. It takes a lot of consistent, determined, planned out work to hold these things together and get majorities in Congress.”

Health care policy experts were skeptical that the policy tweaks to the legislation that have been floated would be enough to change the dynamics around the bill.

“We haven’t really seen the kind of nuanced negotiation on the nuts and bolts of the policy that you need in order to come to some sort of consensus and we haven’t seen the kinds of political organization that is often needed to really line up the votes,” Pearson said. “I think they are trying because it’s politically important, but it doesn’t seem like this round is materially different than what we have seen before.”

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