President Donald Trump met Thursday with the House GOP’s most conservative members, hoping to close a deal that would help ensure passage of the party’s health-care plan by shifting it even further to the right.
The session came after more than a day of almost nonstop negotiations, as Trump and House Speaker Paul D. Ryan, R-Wis., have worked to mollify members of the conservative House Freedom Caucus while simultaneously trying to minimize defections by GOP moderates.
As of late Thursday morning, 36 House Republicans – mainly Freedom Caucus members – had announced their opposition to the bill, known as the American Health Care Act.
GOP leaders appeared to be making some headway in bringing the measure to the floor for a vote Thursday. The price for doing so, however, may be striking popular provisions in the Affordable Care Act that could make it even more difficult to pass legislation in the Senate. This high-wire balancing act, in which Republicans are catering to conservatives in the House with the knowledge that they still must woo moderates to get legislation to the president’s desk, will not only reshape the nation’s health system but could have uncertain electoral repercussions for the new majority.
But with failure not a viable option, Ryan and Trump have been working furiously to win over the large voting bloc of conservatives who control the House bill’s fate. Conservative lawmakers have asked to eliminate much of the bill’s Title I, which not only mandates which benefits participating insurers must cover – such as mental health treatment, wellness visits and maternity and newborn care – but also bars companies from setting insurance rates based on a person’s gender, medical condition, genetic condition or other factors.
The only existing mandates conservatives are open to preserving are ones that bar insurers from denying coverage based on pre-existing conditions and allow children to stay on their parents’ plans until age 26.
Passage of the bill would represent a major political victory for both the White House and House leaders, though the ultimate fate of the bill hinges on the Senate. There are at least a dozen skeptics of the bill among Senate Republicans, who maintain a slim 52 to 48 advantage, and many of them want to maintain some of the current law’s more generous spending components.
More than two dozen House Freedom Caucus members headed to the White House on Thursday morning to meet with Trump, but they left Capitol Hill short of a deal, according to numerous members of the group.
“Having it finished in the next hour would be a herculean task,” said Rep. Mark Meadows, R-N.C., the group’s chairman.
Some members of the group, moreover, want to move the bill even further to the right. Rep. Jeff Duncan, R-S.C., said he was seeking a complete repeal of Title I, including the pre-existing conditions language. Another member, Rep. Ted Yoho, R-Fla., said he had “moved to 100 percent repeal” – suggesting that he would not sign on to the sort of deal the White House is offering.
Essential health benefits, Duncan said, is “not the complete ask.”
“Everyone in the room wants full repeal,” he added. “That’s utopia, right?”
Still, White House officials expressed optimism Thursday that a deal remained within reach. Cliff Sims, director of White House message strategy, tweeted a photo of the president walking in to meet with Freedom Caucus members, along with the line, “Lengthy standing ovation from the Freedom Caucus when @POTUS walked into the Cabinet Room just now. Big momentum toward #RepealAndReplace.”
GOP leaders can afford only 22 defections, given that one Democrat is expected to be absent Thursday. A Freedom Caucus spokeswoman said that “more than 25” members of the group oppose the bill.
The flurry of activity Thursday represented a profound shift from GOP leaders’ previous strategy, under which they insisted that the changes sought by hard-right members would render the bill unable to pass the Senate.
Thursday is the seventh anniversary of the Affordable Care Act, and Republican leaders are eager to mark it with a historic vote demonstrating that eviscerating it has begun. In a sign of how high the stakes are for both parties, former President Barack Obama issued a statement noting that more than 20 million Americans have gained coverage since he signed the law, while the rise in health costs has slowed.
“So the reality is clear: America is stronger because of the Affordable Care Act,” Obama said, adding that Republicans are welcome to work with Democrats to improve the law. “But we should start from the baseline that any changes will make our health care system better, not worse for hard-working Americans. That should always be our priority.”
House Democrats have also urged their GOP counterparts to slow down. Just before 11:35 p.m. Wednesday, the House Rules Committee voted along party lines to waive a rule prohibiting the panel from forwarding a bill to the floor for same-day consideration. The move, colloquially known as “martial law” in the House, will allow GOP leaders to make further changes to the bill and still hold a final vote Thursday.
Democrats questioned why lawmakers would move it to the floor when the Congressional Budget Office had not issued a new analysis of the bill. The additional effects on coverage and federal spending of the provisions still being negotiated Wednesday were also unknowns.
“You’re going to own this, just like we owned the Affordable Care Act,” warned Rep. Alcee L. Hastings, D-Fla., shortly before the panel adjourned for the night. “You’ll rue the day that you did it this way.”
The events of the past 48 hours laid bare party leaders’ struggle to muster enough votes for one of their defining goals: to roll back the 2010 health-care law that helped galvanize conservatives in the years since to wrest control of both the legislative and executive branches from Democrats.
If Republicans fail this initial test of their ability to govern, Trump and Capitol Hill Republicans may face a harder time advancing high-priority initiatives on infrastructure, tax reform and immigration. They might also find themselves navigating strained relationships among themselves.
For much of Wednesday, the Freedom Caucus’s message, spokeswoman Alyssa Farah tweeted, was: “Start over.”
At the same time, four more Republican moderates – Reps. Charlie Dent (Pa.), Frank A. LoBiondo (N.J.), Daniel Donovan (N.Y.) and David Young (Iowa) – announced their opposition Wednesday, increasing pressure on leaders to win over the conservatives.
Ryan summoned more than a dozen members of the moderate Tuesday Group to his office late Wednesday in an apparent bid to curb further defections, a participant said, adding that the speaker outlined the new compromise that was in the works.
“People got to say their piece and react to the proposal. It’s safe to say people had concerns about stripping out essential health benefits, especially at this late hour,” said the lawmaker, who asked for anonymity to describe the closed-door session. “I think they’re short [of votes], and I think they’re considerably short . . . I’m not sure where all this goes tomorrow.”
Ryan had initially warned in an interview Wednesday with conservative radio host Hugh Hewitt that fulfilling conservative Republicans’ demands would violate Senate budget rules and leave the bill vulnerable to a blockade by Democrats.
“Our whole thing is we don’t want to load up our bill in such a way that it doesn’t even get considered in the Senate,” the speaker said. “Then we’ve lost our one chance with this one tool we have.”
That stance appeared to shift late Wednesday, when separate aides in the White House and the House GOP leadership said that a new interpretation of Senate rules had raised the possibility that acceding to the Freedom Caucus’s request might not threaten Senate consideration of the whole bill. But both aides said the provision could still be stripped out once the bill reaches the Senate.
Democratic Senate aides insisted that would be the case. “What the proponents aren’t telling conservative House Republicans is that the plan to repeal essential health benefits will almost certainly not be permissible under Senate reconciliation rules,” said Matt House, a spokesman for Senate Minority Leader Charles E. Schumer, D-N.Y.
In fact, the new negotiations late Wednesday raised the possibility that the challenge would only grow at the other end of the Capitol. Republicans can afford to lose the votes of only two senators, assuming Pence would step in to cast a vote for the health-care rewrite in the case of a tie.
In addition to conservatives, who do not think the proposal does nearly enough to undo the ACA, some moderates fear it will harm their constituents as well as their party’s prospects at the ballot box.
An additional potential hurdle facing the bill is the updated analysis still to come from the Congressional Budget Office, which will reflect changes to the measure that were issued Monday. That analysis could be rendered inaccurate if further changes are made before the vote.
(c) 2017, The Washington Post · Mike Debonis, Juliet Eilperin, David Weigel