GOP House leaders say health bill tweak shows progress, but larger divisions remain

By Paige Winfield Cunningham, Juliet Eilperin and Mike DeBonis
April 6 at 6:00 PM

House Republican leaders presented a tweak to their stalled health-care bill Thursday after Vice President Pence pressured them to show progress toward passing the bill before lawmakers leave for a two-week recess.

On Thursday morning, House Speaker Paul D. Ryan (R-Wis.) invited more than 20 fellow Republicans to his weekly news conference to reveal an amendment aimed at addressing coverage for sicker Americans — and also aimed at pleasing both conservative and moderate Republicans who had opposed the original proposal.

“This brings us closer to the final agreement that we all want to achieve,” Ryan said, later adding that it was “a step in the right direction.”

Those assurances, however, came even as larger divisions over the bill’s content appeared to remain.

The amendment that the Rules Committee approved Thursday afternoon on a party-line vote would set up a federal insurance pool for those with serious and expensive medical conditions such as cancer, congestive heart failure and AIDS. The fund is intended to subsidize coverage for patients with those serious preexisting conditions to lower premiums for healthier patients.

House Ways and Means Committee Chairman Kevin Brady (R-Tex.) said the amendment, sponsored by conservative Reps. Gary Palmer (R-Ala.) and David Schweikert (R-Ariz.), demonstrates “another example of House Republicans’ unwavering commitment to repeal and replace Obamacare and provide immediate relief to those trapped in this failing law.”

Pence made his request to Ryan and Majority Leader Kevin McCarthy (R-Calif.) during a Wednesday evening visit to the White House, according to several individuals briefed on the meeting. These individuals spoke on the condition of anonymity to discuss private conversations.

According to a senior White House official not authorized to speak publicly, Pence conveyed in the intense discussion that the president wanted the House to move immediately on health care to keep the effort to repeal the 2010 Affordable Care Act alive. Trump needs to score a short-term win on the issue, the vice president emphasized, because otherwise lawmakers might retreat.

A House aide said Pence and other White House officials painted a “dire” political picture of what would happen if Republicans fail to act on health care. Ryan also met briefly with Trump, the aide said.

Speaking to reporters on Air Force One Thursday, White House press secretary Sean Spicer described the state of the health-care talks as “constructive.”

“The amendment that Speaker Ryan talked about putting forward in the Rules Committee is something that shows tremendous progress by the team,” he said. “As soon as we get [enough votes], we’ll let you know.”

“We feel very good about where the discussion is going,” he added.

GOP leaders have yet to demonstrate that this amendment alone will resolve the differences between moderates and conservatives that scuttled their initial health-care proposal late last month. The proposal has yet to alter anyone’s vote, according to a House GOP aide.

Rep. Raúl R. Labrador (R-Idaho), one of the hard-right House Freedom Caucus’s most outspoken members, called it a “good” amendment but said he is “not yet” ready to sign on to the underlying measure.

“They’re moving in the right direction,” he said. “We’re still working on it.”

Rep. Tom MacArthur (R-N.J.), a co-chairman of the moderate Tuesday Group and a key player in the intraparty negotiations, praised the idea behind the amendment and said it simply reflected lawmakers’ ongoing policy work. Still, he would not say whether he backs the measure, which provides $15 billion in federal subsidies for insurers covering costly patients.

“Nobody was grasping for an idea to go home with,” MacArthur told reporters. “The reality is we’re still needing to find an ultimate conclusion before we can vote on this bill, and we’re not there yet obviously.”

McCarthy and Majority Whip Steve Scalise (R-La.) said talks would continue through the recess and did not rule out returning lawmakers to Washington early if a compromise comes together.

Huge roadblocks remain in the way of such a deal. At a Politico event Thursday morning, Rep. Mark Meadows (R-N.C.), the chairman of the Freedom Caucus, laid out a path to get “the majority if not the entire Freedom Caucus” to vote for the bill — by extending states’ ability to apply for waivers to key ACA insurance mandates. But there appears to be little appetite for doing that elsewhere in the House GOP.

Rep. Patrick T. McHenry (R-N.C.) said Wednesday that rolling back those mandates — intended to protect insurance access for people with preexisting medical conditions — would be a non-starter: “It goes counter to the president’s promises. It goes counter to the promises of more than 200 members of the House.”

The amendment takes a slightly different approach from high-risk pools, which have long been a staple of conservative health-care retooling plans, and allow insurers to rope off patients with exponentially higher costs from the rest of the population they insure.

The proposal would allow the Health and Human Services secretary to define certain conditions or situations in which insurers could charge higher premium rates, and then the federal government would pay insurers the difference between the customary and elevated rate. To fund it, House Republicans have proposed providing the federal government $15 billion over nine years in addition to the $100 billion in state “stabilization” funds, which can also be used to offset costs for mental-health treatment and out-of-pocket expenses.

Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities, said in an interview that although this approach was better than traditional risk pools, “you are spending a lot of money” in both the stability fund and this new fund “because the rest of the House bill is destabilizing the market.”

Policymakers have struggled for years with the question of how to cover Americans with costly conditions. The 2010 law created a temporary high-risk pool, called the Pre-Existing Condition Insurance Plan (PCIP), which operated from mid-2010 until Dec. 31, 2013, and received $5 billion to help cover consumers’ costs.

Although the law also allowed insurers to waive several federal mandates for this pool of customers — such as free preventive care services and the same premium charges for men and women — a December 2014 analysis by the Commonwealth Fund concluded that “coverage was still very expensive for both enrollees and administrators.”

Hoover Institution research fellow Lanhee Chen, a health-care policy expert who has advised 2012 Republican presidential nominee Mitt Romney and Sen. Marco Rubio (R-Fla.), said in a recent interview that although high-risk pools have encountered problems in the past, those problems could be addressed through sufficient federal subsidies.

“The higher risk [consumers] would have high premiums, but you’d have subsidies,” he said.

Some House members — though not all — see the provision as a companion to potentially allowing states to opt out of the ACA’s ban on charging those patients higher premiums, known as “community rating,” as well as its requirement for insurers to sell policies to all who wish to buy them, known as “guaranteed issue.”

Thursday’s action appeared to be a move rooted more in politics than in policy, sparking a partisan fight at the Rules Committee on Thursday.

Rep. Pete Sessions (R-Tex.), the panel’s chairman, said the addition of the amendment was intended to “lock in ideas so that we now have several weeks to go home and to further amplify” to constituents why the broader health-care bill is good.

“Members can go back home and say, ‘Thank you for the feedback,’ ” he said.

Rep. Jim McGovern (D-Mass.), a Rules Committee member, said the amendment was poorly vetted and would only worsen the GOP bill’s impacts.

“Will Rogers once said, ‘If you find yourself in a hole, stop digging,’ and you guys are digging a damn trench here,” he said. “You keep on going into backrooms and coming out with amendments that might solve some of your political problems, but they do nothing to help the millions of Americans who will lose insurance thanks to your bill.”

The White House meeting that Ryan and McCarthy attended took place inChief of Staff Reince Priebus’s office. Along with Pence, they met with a slew of the president’s top aides, including budget director Mick Mulvaney, chief strategist Stephen K. Bannon and Domestic Policy Council Director Andrew Bremberg.

Priebus — who as Republican National Committee chairman developed close ties to Ryan and other congressional leaders — also pressed for action, one White House official said. Bannon has echoed these calls for action and was one of the most vocal players in pushing for a contentious floor vote in the hours before the legislation was initially shelved, saying that only a “foot on the throat” of House Republicans would get them to fall in line, according to one person close to Bannon.

But even as work on the House bill intensified, many Senate Republicans remained leery of efforts to shift the party debate on health-care policy to the right.

Until the meeting, there was no indication that there would be a formal effort to tweak the bill before lawmakers left Washington.

There may be no immediate independent estimate of the fiscal and coverage impacts that the amendment might have. According to a person with knowledge of discussions at a House Ways and Means Committee staff meeting Thursday morning, House Republicans don’t plan to get a score from the Congressional Budget Office estimating how much a federal high-risk pool would lower premiums unless they are first assured that there are enough votes to pass it.

The $15 billion to pay for the federal pool would come out of the GOP health-care bill’s deficit reduction, reducing the measure’s savings from $150 billion to $135 billion.