Trump, GOP Leaders Try to Seal the Deal on Health Bill

House Republicans released a series of tweaks to their Obamacare-repeal legislation in hopes of wooing both moderate and conservative votes.

President Trump arrives to speak at a rally at the Kentucky Exposition Center in Louisville on Monday.
AP Photo/Andrew Harnik
March 20, 2017, 8:49 p.m.

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.

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