(Bloomberg) — House Speaker Paul Ryan has told senior Republicans that he won’t change the main pillars of his plan to de-fund and partially replace the major Affordable Care Act health programs, even as Republicans search for tweaks that can break their logjam over the legislation.
With a steady trickle of Republicans coming out against the bill, Ryan is sending the message he won’t drop any of its four main elements — refundable tax credits, health savings accounts, the phase-out of Medicaid expansion and the ban on insurers denying coverage over pre-existing conditions — according to a senior Republican aide.
But Ryan is open to tinkering around the edges of some of these policies, such as adding a work requirement for Medicaid or changing the timeline for phasing out the expansion, according to the aide, who spoke on condition of anonymity.
Public posturing by conservatives and moderates in Ryan’s party is leaving little middle ground for compromise, and it’s unclear whether modest revisions will be enough to secure passage of the measure.
"Given how narrowly we’ve threaded this needle," said Rep. Kevin Cramer of North Dakota, "any abrupt change would probably be — could be a deal killer."
Rep. Phil Roe of Tennessee, an influential voice in the party on health care who co-chairs the GOP Doctors Conference, said several significant changes to the health care plan were likely, including an increase in tax credits for people ages 55-65, because costs "are pretty high" for them.
He said the income caps for the subsidies would likely come down from $75,000 for individuals and $150,000 for couples — perhaps to $50,000 and $130,000, respectively.
"I think there’s been some worry about higher-income people" who don’t need the subsidies getting them, he said, adding that work requirements for Medicaid will "probably get in there."
The House Budget Committee, which advanced the measure Thursday, backed four non-binding motions, including one that suggests changing the tax credit to better assist poor people trying to buy insurance and one limiting who can sign up for Medicaid. Budget Chairwoman Diane Black said after the meeting that she didn’t know whether the House Rules Committee would consider such amendments, but that leaders are open to changes.
House Republicans will hold a policy conference on Friday to discuss proposed changes, Roe said. A lot of the final details are "still fluid," Roe said.
President Donald Trump insists that he is behind the bill, but some of his backers are encouraging him to abandon it, too.
‘On track and on schedule’
"We are on track and on schedule," insisted Ryan, voicing determination Thursday at a news conference to keep to a timetable for bringing the bill to the floor next week for a vote.
Trump made doing away with Obamacare a major promise in this presidential campaign, and it’s something congressional Republicans have been promising for six years.
But Republicans have not always clearly defined which parts of the Affordable Care Act they include in “Obamacare,” and keeping the promise to eliminate Obamacare has become a tough test of their Republican-controlled government. It’s also become a big personal test for Ryan as speaker; his non-stop media blitz to defend the bill in recent days has only further entwined his reputation with its fate.
“Today there are a lot of undecideds and lean noes. It depends on what the president decides to do and how strongly he decides to support the package as is,” Rep. Joe Barton of Texas, vice chairman of the House Energy and Commerce Committee, said at an event sponsored by Roll Call. “If we make no changes to it, I would say that it will not pass the House.”
Many conservatives say what is on paper now smacks too much of Obamacare itself, and doesn’t do enough to cut Medicaid and other costs. They are pushing for such changes as moving up the bill’s 2020 freeze on Medicaid enrollment expansion to 2018. But even if those changes occur, some say they still would worry this bill is destined to die in the Senate anyway — something Senate Republicans themselves have been predicting will happen.
Voter counters say the loss of more than 21 Republican votes could kill the AHCA budget measure. (Image: Thinkstock)
Not enough votes
"Right now, there are not the votes," said Rep. Dave Brat of Virginia on CNN Thursday morning. He noted that many conservative think tanks and conservative groups have come out aggressively against the bill, saying it is too much like Obamacare.
After Brat and two other House Republicans on the Budget panel bucked Ryan and voted Thursday against advancing the bill, the trio won praise from outside conservative groups.
"It makes no sense for Speaker Ryan and Chairman Diane Black to force GOP lawmakers to walk the plank and vote for a bad bill that they’ve already admitted needs to be changed,” said Club for Growth president David McIntosh, in a statement.
The other two were Republicans voting "no" were Mark Sanford of South Carolina and Gary Palmer of Alabama.
At the same time, other House Republicans say the bill goes too far, saying it would hurt seniors and low income constituents — and by inference their own political futures. This week’s Congressional Budget Office report saying there would be 24 million fewer insured by 2026 has exacerbated some of those fears.
Rep. Leonard Lance, a New Jersey Republican, said he can’t support the GOP health bill moving toward the House floor because he wants to see the Medicaid expansion continued.
“I do not like the bill in its current form,” he said. “I would like to see a CBO score that is significantly different than the CBO released earlier this week, and I don’t think that’s possible.”
Moderates are wary of Ryan’s efforts to reel in more conservatives because some of those changes could make the measure even harder for them to support. Moving up the end of Medicaid expansion from 2020 to 2018 is a "nonstarter," said Rep. Charlie Dent of Pennsylvania, a co-chairman of a group of House moderates. He said that would be too disruptive to markets and many individuals.
Dent also said there are concerns that the bill as now written provides "insufficient" levels of tax credits to help some people buy health care. For their part, many conservatives have complained those credits go too far toward creating a new entitlement — and at least should be means tested.
House Republican vote counters have only now started putting together their war charts, but the initial math doesn’t look great. That’s because 216 backers will be needed for passage if all 430 currently sitting House members show up and vote on the bill. With the 193 House Democrats expected to vote as a bloc against repealing Obamacare, Ryan can’t lose more than 21 Republican votes.
And far more members from the right and left of the GOP conference are already saying they will vote against the bill, as is — or that they remain undecided.
The bill’s ultimate fate in the House could come down to conservatives making a choice between sticking with their rigid, principled stands or buckling under the pressure of voting for some kind of repeal bill that has a chance of getting signed.
"If you’re a Republican, just go through the bill and count the things that we have been campaigning on for years that we’ve been railing against with Obamacare, and they are in this bill," said Rep. Steve Womack of Arkansas. “I just can’t fathom us getting it to this stage of the game and not moving it across the finish line.”
Rep. Mark Meadows of North Carolina, chairman of the ultra-right House Freedom Caucus, said Thursday on MSNBC that the next week of negotiations with Republican leaders and the White House will be "critical," and that "I’m willing to invest the political capital to get it right."
Meadows and Sen. Ted Cruz of Texas argued in an editorial Thursday in the Wall Street Journal that Republicans essentially need to start over and write a new health care bill.
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