WASHINGTON— Putting President Trump at the center of a fierce intraparty clash, conservative members of Congress and House GOP leaders are waging a standoff over the American Health Care Act (AHCA).
Republicans have vowed to dismantle Obamacare since it passed with only Democrat votes in 2010, but reaching agreement on what should come next since gaining full control of Congress and the White House has proven difficult.
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After seven years of struggling to write a replacement bill, House Republican leaders released the AHCA on Monday. The House Ways and Means and Energy and Commerce committees began "mark-up" sessions, which consist of debating and potentially amending a "clean repeal" of the Affordable Care act, on Wednesday.
After nearly 18 hours of debate the bill claimed its first major victory. The House Ways and Means Committee early Thursday morning voted along party lines 23-16 to advance the portion of the AHCA which relates to tax provisions.
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The House Energy and Commerce Committee, after 27 hours of debate, approved its half of the House GOP's plan to repeal and replace ObamaCare on Thursday.
The Senate needs 60 votes to repeal Obamacare. However, there are only 52 Republican senators, so Republicans are using the "reconciliation" budget process to pass AHCA, which only requires a 51-vote majority. Every measure, however, has to have a budgetary impact.
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But major obstacles remain for the repeal-and-replace plan, as a significant number of conservatives emphatically object to key provisions and have vowed to vote against the measure.
ACHA looks to preserve some of the more popular elements of Obamacare, including protections for people with pre-existing conditions (though insurers would be allowed to charge higher premiums to individuals whose coverage has lapsed) and letting children stay on their parents' insurance plans until the age of 26.
The bill would end federal subsidies based on people's income and all of the Obamacare taxes, according to a copy of the proposal. In place of the Obamacare subsidies, the House bill, starting in 2020, would give tax credits based on age instead of income. For a person under age 30, the credit would be $2,000. That amount would double for beneficiaries over the age of 60, according to the proposal. It would also allow insurers to charge higher premiums for people whose coverage lapses and give states money to create high-risk pools for some people with pre-existing conditions.
The ACHA eliminates Obamacare's Medicaid expansion in 2020. States could still cover those people if they chose but with dramatically less federal money to do so. It leaves decisions about mandatory or essential benefits to the states.
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Key conservative Republicans in the House and Senate are calling the plan's refundable tax credits a "new entitlement program." A vote to repeal Obamacare, they argue, should be a separate a measure from legislation that replaces former President Obama’s signature legislation.
The Republican Study Committee (RSC) and the House Freedom Caucus are at odds on what concessions are needed for their members to support the House GOP's ACA replacement bill.
RSC, which is comprised of 170 conservative lawmakers, is backing two proposals. The first would freeze Medicaid enrollment under ACA's expansion starting in 2018, as opposed to the 2020 date in the current bill. The second supports a Medicaid work requirement for able-bodied adults who do not have children. The group also is pushing to restructure the tax credits proposed in the bill.
Members of the Freedom Caucus, a bloc of about 40 of the most fiscally conservative House Republicans, argue those changes would not be enough to gain the group's support.
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The bill would dismantle Obamacare's unpopular individual mandate which fines people who don't buy insurance, but ACHA still includes penalties for individuals who fail to maintain coverage continuously. If their coverage lapses and they decide to re-enroll, they would have to pay a 30 percent boost in premiums for a year.
Members of the Freedom Caucus want the bill to erase coverage mandates, arguing that their top goal is to reduce consumers' insurance costs, including premiums.
It would eliminate federal funding of Planned Parenthood and restrict abortion access in covered plans on the health exchange, which could be an obstacle if the bill gets to the Senate. Sens. Lisa Murkowski, R-Alaska, and Susan Collins, R-Maine, have both said that a prohibition on Planned Parenthood funding shouldn't be part of the bill. Their support will be crucial once the bill moves to the Senate, since there are 52 Republicans and the GOP will need 50 votes to pass it.
House Speaker Paul Ryan (R-Wisconsin) warns that Republicans will ultimately face a take-it-or-leave-it proposition with the bill.
Ryan during his weekly press conference on Thursday delivered a 23-minute presentation in which he sought to sell conservatives and the public on the House's current plan.
"This is the closest we will ever get to repealing and replacing Obamacare. The time is here. The time is now," Ryan said. "It really comes down to a binary choice" between voting for the House bill or leaving ACA in place.
"We are doing an act of mercy by repealing [the ACA] and replacing it with patient-centered health-care reforms," Ryan said. "If we did nothing the law would collapse, and leave everybody without affordable health care."
It's now or never, and it's this or nothing, House Majority Whip Steve Scalise (R-Louisiana) cautioned.
"At the end of the day, members are going to have to make a choice: Do they want to vote with Nancy Pelosi or do they want to support President Trump to get that bill to his desk?" Scalise told Fox News.
The exact details of any legislation will also be shaped by findings from the Congressional Budget Office (CBO) that project how much it will cost and what it will do to the federal deficit. Top Democrats are citing the lack of a CBO report as a reason the effort should be postponed.
Democrat Rep. Lloyd Doggett said the GOP bill is being kept "as secret as Donald Trump's tax returns."
"To consider a bill of this magnitude without a CBO score is not only puzzling and concerning, but also irresponsible," said Rep. Richard Neal, the top Democrat on the Ways and Means panel.
House Democrat leader Pelosi, who in 2010 notoriously declared, "We have to pass the [Affordable Care Act] so that you can find out what is in it," has seemingly changed her mind when it comes to transparency. Pelosi sent a letter to Speaker Ryan on Tuesday demanding Republicans release all of the information about the AHCA so voters can see the "full impact" of the legislation.
"The American people and members have a right to know the full impact of this legislation before any vote in committee or by the whole House,” the letter states.
The president, who won the White House by championing his ability to strike business deals, hosted a bowling party at the White House for members of the House Freedom Caucus in an effort to convince them to support the ACHA.
He then confidently predicted Thursday that he will ultimately be successful.
"Despite what you hear in the press, health care is coming along great. We are talking to many groups and it will end in a beautiful picture,” he tweeted.
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!
— Donald J. Trump (@realDonaldTrump) March 9, 2017
Battling to meet a key campaign pledge 50 days into his presidency, Trump warned on Friday that the Affordable Care Act was designed for consumer costs to soar after President Obama left office. He urged lawmakers to support the GOP health-reform plan if they want to "save Americans from imploding Obamacare disaster."
Saying 2017 "would be a disaster for Obamacare," Trump warned House GOP leaders in a Friday meeting, "That's the year it was meant to explode, because Obama won't be here. That's when it was supposed to ... get even worse. As bad as it is now, it'll get even worse."
Vice President Mike Pence is heading to Kentucky on Saturday to try to whip up support for the bill – and win over Sen. Rand Paul (R-Kentucky), who has flat-out said he opposes it.
The GOP proposal heads to the Budget Committee next and remains on track to land on the House floor by month's end.
