Alice Ollstein contributed reporting.
The movement to repeal the Affordable Care Act appears to be approaching a do-or-die moment for Republicans, as the clock ticks on dismantling Obamacare in time to also tackle tax reform before Congress’s summer recess. Many of the differences that dogged Republicans about repealing and replacing the law remain. But GOP lawmakers, particularly in the House, seem intent on moving forward, if a leaked a draft of legislation is of any judge.
Congressional leaders are signaling a “now or never” strategy that will dare the Republicans to stand in their way, regardless of their disagreements over the details of repealing the Affordable Care Act, according to a Wall Street Journal report.
“You’re a Republican, you’ve been running to repeal Obamacare, they put a repeal bill in front of you,” Doug Badger, a longtime Republican leadership health policy adviser, told the Journal. “Are you going to be the Republican senator who prevents Obamacare repeal from being sent to a Republican president who is willing to sign it?”
Republicans have had seven years to coalesce around an Obamacare replacement, during which GOP lawmakers took dozens of vote to repeal the ACA, but in the months since Donald Trump’s surprise election, have only inched a little closer to settling on a plan moving forward. GOP lawmakers were able to pass an Obamacare repeal bill that then-President Obama vetoed in 2016. But now that they have a President Trump in the White House who will sign it, they’ve raised concerns about the timing, funding and general shape of an ACA replacement. According to the Wall Street Journal report, leadership is ready to move forward right away with a replacement strategy that resembles the previous proposals put forward by House Speaker Paul Ryan (R-WI) rather than fully litigate all of the differences within the House GOP conference. The risk of such a strategy is that it takes only a few defections — about two dozen members in the House and three Republicans in the Senate — to torpedo the repeal bill.
House Republicans were presented with a broad outline of alternative ideas — including expanding health savings accounts and block granting Medicaid — that have been mainstay of conservative proposals in a meeting before last week’s President’s Day recess. On Friday, Politico surfaced a draft legislative package that would rework the tax credits available to Americans to buy individual insurance, drastically reduce the federal government’s contributions to Medicaid through a per capita cap, and offer funding for states to help cover high-risk individuals, via risk pools or other mechanisms.
It’s unclear whether the text is what GOP leaders plan to move forward in the weeks to come, when mark-ups of Obamacare repeal legislation are expected. Lawmakers want to use the process of reconciliation, which avoids a Democratic filibuster in the Senate, to repeal Obamacare. But the process’ rules limiting its use to budgetary items that reduce the deficit are another wrench for Republicans.
Already House conservatives — including the leaders of the influential groups the House Freedom Caucus and the Republican Study Committee — are objecting to some of the ideas being floated, and particularly the proposal to offer refundable tax credits for individual insurance.
“It provides for a new entitlement program, is my belief,” Rep. Mark Meadows (R-NC), the chairman of the House Freedom Caucus, told reporters on Capitol Hill Monday. He said that leadership had indicated to his staff that some changes have been made to the draft text, but that they “were not substantial changes” and the leaked text “may be close to the final version.”
“There are still a number of issues to work out in terms of getting to a consensus,” Meadows said.
Part of the challenge facing Obamacare foes is that the White House has stayed out of the fray, at least publicly, in the debate surrounding Obamacare repeal’s key questions. Administration officials have participated with listening sessions with various groups of lawmakers, and the confirmation of Health and Human Services Secretary Tom Price is seen as a significant step forward in getting the White House and Capitol Hill on the same page. But Trump himself has delivered mixed messages on his priorities moving forward.
In a meeting Friday afternoon with Gov. John Kasich (R-OH) — who has pleaded with GOP lawmakers to take a more moderate approach to the ACA, particularly when it comes to Medicaid — Trump said he like Kasich’s ideas better, the Washington Post reported, when he was reminded that House Republicans were working on their own strategy.
Furthermore, two governors — Gov. Terry McAuliffe (D-VA) and Gov. Brian Sandoval (R-NV) — told the Hill that Trump reiterated to them that his administration was offering its own replacement plan in two to three weeks. In a meeting with lawmakers, the governors were also told that the House draft bill “does not reflect current thinking,” Senate GOP No. 2 John Cornyn (R-TX) told the Hill.
“I was told [the leaked draft] was dated the 10th and is somewhat dated,” Sen. Bill Cassidy (R-LA), who has introduced his own replacement plan, told TPM. He added that he hadn’t heard anything else about the House’s plans going forward but that he was encouraged by the meeting between Kasich and Trump.
Governors have their own stake in the Obamacare repeal battle, and most Republicans agree that they would like to see states have more flexibility in how they implement their Medicaid programs. But according to internal Republican Governors Public Policy Committee documents posted by Vox, they are still debating what options states that expanded Medicaid under the ACA should have in exchange for a GOP overhaul of the program.
Some senators from expansion states — which have 20 Republicans in total representing them in the Senate — have echoed the governors’ concerns how to handle the Medicaid expansion.
“I think there is now a realization of the importance of addressing the people who are on expanded Medicaid,” Sen. Rob Portman (R-OH) told TPM Monday, while pointing to the meetings that Kasich and other GOP governors have had with Trump.
Trump met with governors Monday where he hinted again that his own plan was coming. (He later promised the plan would be “fantastic” in a meeting with insurers.) Speaking with the governors, he expressed surprise that that health care was such an “unbelievably complex subject.”
“Nobody knew that health care could be so complicated,” Trump said.