House Republican leaders are counting on a visit by President Trump and a last-minute policy rewrite to push their health care legislation over the finish line, but their margin for error will be razor-thin as scores of members have yet to commit to supporting the bill.
Republican leaders released a slate of changes Monday night aimed at drawing votes from moderate and conservative Republicans. But finding the legislative “sweet spot” that House Speaker Paul Ryan has been seeking is proving difficult, as members on the Left and Right expressed reservations about the beleaguered bill.
Member concerns seem to be centering on the interplay between the House and the Senate, with House members frustrated that their bill cannot go farther to unravel Obamacare because of Senate rules or wary that the Senate will strip out policies they consider must-haves.
House Freedom Caucus Chairman Mark Meadows said Monday evening that despite leaders’ proposed changes to the bill, he and several of his HFC colleagues will vote against it because it does not go far enough. He said there are enough “no” votes in the conservative Freedom Caucus to keep the bill from passing.
"History shows that it typically doesn't get better in the Senate," he said.
The grousing from conservatives comes despite an overture from leadership in the form of a proposed change that would phase out Obamacare taxes a year earlier than originally planned.
Instead, conservatives want the House bill to repeal the Affordable Care Act’s essential-health-benefit requirements, but leadership believes that doing so would run afoul of Senate rules. The legislation is being brought to the floor under the so-called budget-reconciliation process, which allows Republicans to pass their bill with a simple majority and without any Democratic votes, but discourages policy changes with a minimal impact on the budget.
The same Senate procedure, called the Byrd Rule, endangers a provision that would prohibit tax credits from being spent on plans that cover abortion. Members of the House Pro-Life Caucus met with Vice President Mike Pence at the White House on Monday, but Rep. Trent Franks, a member of the Pro-Life Caucus and the Freedom Caucus, said he still has concerns.
“The way to get me to ‘yes’ is to assuage any concerns I have about the pro-life provisions being eliminated … and including [the repeal of] these Obama [regulations] in the bill because if we don’t, the policy itself will be at risk,” he said. “What we’re doing here, whether we realize it or not, is we’re letting the Senate rules subordinate the policy discussion here.”
House leaders are counting on an endorsement from the antiabortion National Right to Life Committee to help bring along some of those members. The group announced it would key-vote the bill, meaning that anyone who votes against it would have a less-than-100-percent rating on its scorecard.
Leaders are also relying heavily on Trump—who spent Monday evening rallying with a friendly crowd in Louisville, Kentucky—and his administration to bring along conservatives. They are betting that members from deep-red states don’t want to be on the wrong side of a president who excelled in their districts last November.
Meanwhile, leadership also plans to amend the legislation to create a $75 billion reserve fund to help low-income seniors pay their premiums, which would jump significantly under the Republican bill. But the mechanism to do so drew some questions from moderates, whom it was created to appease.
Rep. Charlie Dent, cochairman of the moderate Tuesday Group, said he is concerned that the House amendment would not actually set up the tax credits for low-income seniors, but rather instruct the Senate to do so, meaning House members would vote for the bill without being certain it will address their concerns.
"I would rather see the credits enhanced in the House bill as opposed to depending on the gentle tender mercies of the U.S. Senate," Dent said.
Rep. Ileana Ros-Lehtinen said she will vote against the bill because no amount of budgetary plus-ups could mitigate the damage that it would do to her district, which has the most recipients of Obamacare of any congressional district.
“It would be practically impossible for the leadership to make the kind of changes that could accommodate the needs of my constituents. They will be severely hit,” she said.
Still, some changes did flip some votes from "no" to "yes." The leadership amendment, which is expected to be added to the bill in the Rules Committee on Wednesday, will include provisions that would institute optional Medicaid work requirements and block grants for states.
The provision is a concession to members of the Republican Study Committee, who met with Trump last week and committed to vote for the bill if its asks were met.
Even if the bill passes the House this week, it'll need changes before it could pass the Senate, where enough Republicans have already come out in opposition to sink the bill in its current form. Some senators from states that expanded Medicaid under the Affordable Care Act have criticized the bill's efforts to roll that back in 2020, as millions fewer low-income people would have coverage and state budgets take a hit without the enhanced federal funding.
Other conservatives, such as Sens. Rand Paul and Mike Lee, want to start over, repeal much of the ACA, and then begin the task of reforming the health care system. Earlier this year, the nonpartisan Congressional Budget Office found that at least 18 million people would lose coverage in the first year if Republicans repealed the ACA without a replacement. The CBO found that 24 million more people would be uninsured in the House bill than under Obamacare over a decade, but it would reduce the federal deficit by $337 billion.
Senate aides are prepping for a fight over the Byrd Rule. The parliamentarian's interpretation of the rule could have major consequences. One senior Senate aide said that about a dozen provisions are being debated as to what should or should not comply. Another Senate aide said, "Democrats are very, very far from any decisions on this process."
Reports suggest that two particular provisions are suspect: allowing insurers to charge the oldest enrollees five times as much as the youngest, and the surcharge for people who don’t maintain continuous coverage.