The Washington Post
WASHINGTON — A Republican proposal to revise the Affordable Care Act claimed its first major victories Thursday amid a backlash that both Republican leaders and President Donald Trump spent the day trying to tamp down.
Trump met with several conservative critics of the plan, signaling both a willingness to negotiate its details and that it does not yet have enough votes to emerge from the House. More acknowledgment of the proposal’s problems came from Senate Republicans, who suggested Thursday that the measure is moving too quickly through the House and in a form unlikely to succeed once it moves to the upper chamber.
Yet the plan emerged from two key House committees Thursday, and House Speaker Paul Ryan, R-Wis., its top booster, insisted that the pending legislation represents the “only chance we’re going to get” to fulfill the GOP’s longstanding promise to undo the Affordable Care Act.
The GOP proposal cleared the Ways and Means and the Energy and Commerce committees on party-line votes after marathon sessions that lasted through Wednesday night and into Thursday. It now heads to yet another panel, the Budget Committee, and it remains on track to land on the House floor by month’s end.
But the proposal faces challenges with both GOP conservatives and moderates, in addition to Democrats, many of whom questioned the lightning-fast process and raising dueling qualms about its policy provisions.
Even Senate Majority Leader Mitch McConnell, R-Ky., appeared to echo a Democratic attack on the House legislation, saying lawmakers need to see the nonpartisan Congressional Budget Office estimate of how the bill will affect the federal deficit and the number of insured Americans.
“I think we need to know that,” McConnell said at a breakfast sponsored by Politico, adding that the report could be released by Monday.
Trump and Ryan have adopted diverging approaches to critics of the overhaul. While Trump has endorsed the legislation, he has expressed a willingness to make deals with its critics in recent days, while Ryan has emphasized the precarious nature of the legislation House leaders have drafted, all but ruling out substantial changes to the bill before it comes up for a final vote.
At an unusual Thursday news conference carried live on cable news channels, a shirt-sleeved Ryan gave a 23-minute presentation. Republicans, he said, face a “binary choice” — vote for the House bill, or let the ACA survive.
“We as Republicans have been waiting seven years to do this,” Ryan said. “This is the closest we will ever get to repealing and replacing Obamacare. The time is here. The time is now. This is the moment.”
Hours later, leaders of the hard-right House Freedom Caucus visited the White House and made a personal case to Trump to modify the legislation — changes that Ryan and other House leaders believe would imperil it by alienating more moderate Republicans.
“I didn’t hear anything that said it’s a binary choice at the White House today,” said Rep. Mark Meadows, R-N.C., the Freedom Caucus chairman, who met with Trump and other lawmakers at the White House.
Meadows declined to detail the changes he and other conservatives are seeking, but they have leveled three broad objections to the Ryan-backed bill: that the system of tax credits it creates constitutes a new government entitlement, that it does not do enough to curtail the ACA’s Medicaid expansion and that it largely leaves the ACA’s insurance coverage mandates in place.
Trump and his deputies have spent the past several days carefully wooing members of the Freedom Caucus with lengthy lunches with the president, calls with staff and friendly meetings with White House Budget Director Mick Mulvaney, himself a founding member of the Freedom Caucus.
Yet it remains unclear when or how any tweaks to the measure would occur.
Trump and Ryan have both sent strong signals this week that they consider the tax credit issue settled, and several Freedom Caucus members said they were now focused on beefing up the GOP bill’s attack on the ACA insurance mandates.
House leaders involved in drafting the bill largely steered clear of the insurance mandates, having concluded that more significant changes would be more difficult to get through the Senate. But conservatives said they were not interested in watering down the House bill preemptively.
“I think we can probably be more aggressive,” said Rep. Ron DeSantis, R-Fla. “So I think that’s what (Meadows and Jordan) were talking to the president about, saying, ‘Mr. President, if you want to reduce costs, this may not do it.’”
Another influential House conservative group, the Republican Study Committee, proposed amendments to the Medicaid portion of the GOP plan that would wind down the ACA Medicaid expansion beginning in 2018 rather than 2020, and also require “able-bodied, childless adults” to seek work in exchange for Medicaid benefits.
Trump’s willingness to negotiate — expressed in a Wednesday evening meeting with leaders of conservative activist groups in addition to Thursday’s session with Freedom Caucus leaders — came amid a barrage of attacks from Democrats and criticism from health-care industry groups.
Trump sought to calm fears about the process in an afternoon tweet: “Despite what you hear in the press, healthcare is coming along great. We are talking to many groups and it will end in a beautiful picture!”
The accelerated pace has drawn criticism from Democrats, who contrasted it with the lengthy deliberations that took place before passage of the Affordable Care Act, as well as from some Republicans.
One of those Republicans, Sen. Tom Cotton, of Arkansas, tweeted early Thursday that the House should “start over.”
“Get it right, don’t get it fast,” Cotton wrote from his political account.
In a Thursday afternoon interview with The Washington Post, Cotton threw more cold water on the House legislation, including the proposed tax credits to help people pay for insurance.
“The bill that was introduced Monday night cannot pass the Senate,” he said. “And I don’t think it will be brought to the Senate for a vote.”
Cotton said many of his colleagues hold similar views: “They might not have spoken publicly about it, but I can tell you a number if not a majority of Republican senators think that this process has been too breakneck, too slapdash and they do not see a good solution for the American people coming out of the House bill as drafted.”
Four other GOP senators in states that accepted Medicaid expansion under the ACA, also known as Obamacare, have expressed concerns about changing the way the program is administered.
One of those senators, Rob Portman, R-Ohio, reiterated his concerns Thursday after meeting with Vice President Mike Pence and Health and Human Services Secretary Tom Price.
“That concerns me if it provides less certainty for the expanded Medicaid,” Portman said. “We’ll see.”
The immediate challenge for Trump, however, is getting the legislation through the House, and lawmakers said his meeting Thursday with its most vocal conservative critics showed he is taking a hands-on approach.
“We’re appealing to a president who likes to negotiate, who likes to win, and who likes to keep his promises,” said Rep. Raúl Labrador, R-Idaho, a Freedom Caucus member.
The Freedom Caucus huddled for more than an hour at the Capitol on Thursday after Meadows and the other lawmakers returned from their White House lunch to whittle down a final list of demands.
Meanwhile, the American Action Network, a group with close ties to Ryan, said it would launch television ads in more than two dozen media markets urging intransigent conservatives to support the plan.
Many House conservatives said they have yet to be swayed. Several said they worry that the White House and Ryan are sending completely different messages about how much influence rank-and-file members will have over the final health care law.
“What we hear from the White House is, this is a work in progress,” said Rep. Mark Sanford, R-S.C. “Then we hear from leadership, take it or leave it.”
Several members said they’re concerned that promised administrative actions to scale back expensive essential health benefits mandated by the ACA — such as birth control, maternity care and free preventative care — will never materialize if voters balk at the changes.
“Given his sensitivity to public opinion, you’re telling me he’s going to make that tough call?” Sanford said. “And, if not, we’re going to own it.”
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