House Speaker Paul Ryan (R-WI) and his top lieutenants put on their best game face Tuesday morning, insisting that they and the Trump administration were well on track to repeal and replace the Affordable Care Act this year. They appeared unfazed by the mounting concerns of consumers, insurers, health care executives and governors that the GOP may be headed down a treacherous path.
“I fully recognize and respect the strong feelings that people have about this issue,” Ryan told reporters at the U.S. Capitol. “We should be passionate about this issue. It is about people’s lives. This affects every person and every family in America.”
Ryan argued once again that Americans are trapped in a Democratic-concocted health care system with runaway premiums and co-payments and limited choices. “This law is in a collapse, and we have an obligation to rescue people from that collapse,” he declared.
But if anything is collapsing at this point, it is the already shaky consensus among Republicans in the House and Senate over how – or even whether – to proceed in making good on their campaign pledge to dismantle and replace Obamacare. President Trump and congressional Republican leaders already have missed self-imposed deadlines repeal and replacement legislation and now appear to be taking a more piecemeal approach to cobbling together elements of a plan.
Moreover, some moderate Republicans are pressing for alternative proposals that would “repair” rather than replace Obamacare or even allow states to choose whether to continue with the existing program or opt for a more conservative, market-driven system.
From the beginning, it was always assumed that the Republicans would have a much tougher time pushing a budget resolution and related legislation through the Senate than the House. That’s because of the GOP’s seemingly unstoppable 247 to 188 seat majority in the lower chamber, in contrast to the Republicans’ narrow 52 to 48 seat majority in the Senate. The defection of just three moderate Republicans in the Senate potentially could grind to a halt the GOP effort to repeal Obamacare.
But 40 or so members of the House’s far right Freedom Caucus blew up that political calculus Monday night after agreeing among themselves to refuse to support anything but the most extreme version of Obamacare legislation, comparable to the 2015 legislation passed by the Republican-controlled House and Senate and vetoed by Democratic President Barack Obama.
That bill was essentially a nuclear option for ridding the country of Obamacare. The legislation repealed the mandates for individuals to buy insurance and employers to provide insurance. The measure eliminated the law’s premium subsidies for low-income Americans and wiped out the hundreds of billions of dollars in taxes imposed to finance the operation of the government-operated health care exchanges. And it rolled back expanded Medicaid coverage for millions of poor adults who previously had no coverage – a provision strongly backed by Republican and Democratic governors alike.
“If it’s less than the 2015 [legislation], we will oppose it,” Rep. Mark Meadows (R-NC), the chair of the Freedom Party, told reporters Monday night. Meadows also said that he and his members might demand simultaneous action on repeal and replacement legislation – something virtually impossible to achieve. It is the worst kept secret in town that Trump and congressional leaders are nowhere near agreement on a plan to overhaul the health care law without stripping 20 million or more Americans of their current coverage under Obamacare.
For the time being, the GOP leaders’ best hope is to push through a measure repealing most of Obamacare while hoping they can subsequently enlist Democratic support on replacement legislation that preserves many of Obamacare’s most popular features, like the ban on insurers discriminating against people with pre-existing conditions and the provision allowing children to stay on their parents’ insurance plans until age 26.
By staking out arguably the most extreme approach to ending Obamacare, Freedom Caucus members have left Ryan, McConnell and other Republican leaders with practically no wiggle room in negotiating with insurers and health care providers or placating more moderate members of the two chambers who are beginning to freak out about growing protests by voters in their districts and states.
And if the Freedom Caucus members balk at negotiating a less extreme budget resolution that preserves some elements of the existing law, then Ryan will have a tough time mustering a minimum of 218 votes to repeal Obamacare.
Ryan, Ways and Means Committee Chair Kevin Brady of Texas and Greg Walden, chair of the House Energy & Commerce Committee, have adopted a more piecemeal approach, holding hearings on various elements of a replacement plan – such as health care savings accounts and new ways of differentiating the premium rates between younger and older applicants – and vowing to stitch them together eventually, in consultation with Trump’s new secretary of health and human services, former Rep. Tom Price of Georgia.
“We are taking a step by step approach, so people can see the changes that we are making and see how they will help,” Ryan said today. “And working with Secretary Price, we will have a stable transition where no one has the rug pulled out from under them while we work towards a better, more stable system. So this step by step approach will rescue people from Obamacare’s collapse and give every American access to affordable, quality health care.”
Yet by taking this more deliberative approach, the Republicans have begun to lose momentum – giving their opponents more opportunity to galvanize public opinion against the GOP approach. “I don’t know if it’s perilous for the Republicans, but certainly I would say that the speed is slipping,” Michael Tanner, a health care policy expert with the libertarian Cato Institute, said in an interview.
One of the Republicans’ biggest fears is that while they dither over a strategy and plan to replace Obamacare, the existing subsidized private health care market will begin to collapse, with major insurance companies continuing to bail out of the program and millions of Americans threatened with the loss of coverage or even higher premiums next year.
The Trump administration has promised to provide some “market stabilization” to get the insurers and consumers what is certain to be a rocky transition period, but the insurance companies are beginning to make demands contrary to the views of the Freedom Caucus and other more conservative lawmakers.
For instance, Blue Cross Blue Shield Association lobbyists presented an industry-backed plan to officials of the White House and Department of Health and Human Services Feb. 6 that calls for preserving premium subsidies for low-income Americans and the mandate requiring everybody to buy insurance until Republicans can create state “high risk pools” for providing coverage to older and sicker people. The industry proposal, first reported by Axios, would also permanently repeal Obamacare taxes on insurers and others.
The question of what to do about Obamacare taxes, which underwrite the cost of the health care plan and generate roughly $1.1 trillion over a decade, is a particularly thorny question. Rep. Jim Jordan (R-OH) and other members of the Freedom Caucus favor totally eliminating the taxes as part of the Obamacare repeal, but that would leave the GOP with few resources to fund their alternative approach.
Robert Laszewski, a health policy consultant and sharp critic of the Affordable Care Act, asserted today that for all of their challenges, Ryan and other GOP leaders were making headway on assembling a feasible replacement plan.
“Obamacare was failing, it was unstable, and we just had an enrollment period that’s going to do nothing to change that,” he said in an interview. “All of the ideological arguments aside, Obamacare has to be fixed.”