House Republicans, Deeply Divided, Face Painful Choice on Health Vote


WASHINGTON — For the House Republicans who have never served under a Republican president — roughly two-thirds of them — the vote scheduled for Thursday on a measure to replace President Barack Obama’s health care law is a legislative fantasia, the culmination of seven years of campaign promises impeded by Mr. Obama’s veto pen.

But weeks of back-room machinations to bring a disparate group of lawmakers on board have left many Republicans with an excruciating choice: Pass a bill with an extremely limited constituency that could well wreak havoc with their own voters, and with Republicans’ re-election prospects, or vote it down, undermining President Trump’s agenda.

Speaker Paul D. Ryan said Wednesday that he was confident the House would pass the bill. But as of late Wednesday, roughly 30 Republicans had said they either would vote against the measure or had not made up their minds. That left the bill’s sponsors short of the 216 votes needed, and on Wednesday night Mr. Ryan scheduled a meeting in the Capitol to try to win over skeptics.

If House Republicans reject the measure, the working relationship between the White House and Republican leaders in Congress, still in its infancy, will suffer a powerful blow. In Washington, failure often begets more failure, as opposition forces strengthen, alliances fragment and the thin foam of bipartisanship evaporates.

“How do we have any momentum to do anything else?” asked Representative Richard Hudson, Republican of North Carolina. “Without this bill, I don’t know how you do tax reform,” he said. If the bill fails, “it’s going to have negative repercussions for all of us.”

Mr. Trump, a man who rushes to hang his name in gold anywhere he can, has rejected the nickname that some have given the House bill: Trumpcare.

But he has begun a last-minute campaign to both sweet talk and vaguely threaten fellow Republicans into supporting the leadership’s hastily written bill, though the measure, which would replace the Affordable Care Act’s health insurance mandate and generous subsidies with tax credits to buy insurance, has been criticized by the right and the left.

Mr. Trump met with a group of the most conservative House members at the White House on Wednesday, and Republican leaders are depending on him to finish the job. Indeed, this week many Republicans have begun to acquiesce to his and the House leadership’s desires, accepting that the bill, however flawed, is the best they are going to get.

At least for now, though, too many have not.

“The bill maintains Obamacare’s overall structure and approach, an approach that cements the federal government’s role in health insurance,” said Representative Rick Crawford, Republican of Arkansas, an opponent of the bill who represents the concerns of the conservatives.

Other more moderate members expressed opposite objections. “Under the current proposal, many South Jersey residents would be left with financial hardship or without the coverage they now receive,” said Representative Frank A. LoBiondo, Republican of New Jersey. “Our seniors on Medicare already struggle to make each dollar stretch.”

Some Republican leaders and those charged with drumming up votes suspect that some of the more conservative members are simply trying to force Mr. Ryan to cancel a vote on the bill so they do not have to go on record against Mr. Trump. But moderates may feel the pressure of voters: Large protests against the bill are planned for Thursday.

Further hampering them, House Republicans failed to do the grueling work of building a coalition outside Washington as Democrats did with the Affordable Care Act in 2009. While anti-abortion groups have warmly embraced the bill, which could restrict coverage of the procedure, it lacks other advocates. Doctors, nurses and hospitals have come out strongly against the measure, and insurance companies have been largely skeptical.

Even if Mr. Ryan manages to secure the bare minimum of votes required, the bill that would pass the House would not become law. The Senate expects to make significant changes in the legislation, dragging out the process deep into the spring, if it can pass any version at all.

Senate Republicans, largely those from states that chose to expand their Medicaid programs under the Affordable Care Act, so far have not seemed susceptible to pressure from leaders and Mr. Trump, listening instead to governors and constituents concerned about significant reductions in benefits.

Part of the bill’s problem is time itself. Much has changed in the years since the Affordable Care Act passed, with millions of Americans, many in red states, now getting health insurance as a result of the law, as well as treatment for the prescription drug addictions that have plagued scores of communities.

“My goal for this whole process was to help the people the law harmed and not harm the people it helps,” said Representative Dan Donovan, Republican of New York. At the same time, a fair number of conservatives would like to see those benefits greatly reduced, the central tension of the Republican debate.

As a result, it remains difficult to imagine a bill that could find its way out of the Capitol to Mr. Trump’s desk, given the broad disparities in what Republicans now seek.

Even if they can come together, House Republicans risk making the same mistakes Democrats made in the beginning of Mr. Obama’s term, when they pushed through what came to be known as Obamacare. That achievement, monumental at the time, ended up dragging down a once formidable Democratic majority and reducing the ability of Democrats to pass more legislation during his presidency.

Yet if the bill fails, Republicans in the House could end up like House Democrats under President Bill Clinton, who passed a controversial energy tax that was reduced to rubble in the Senate, but remained an albatross for Democrats in the 1994 elections.

The Democratic majority repeated that error in the early years of the Obama administration when the House passed a highly unpopular bill to cap the carbon emissions that cause climate change, only to see it go nowhere in the Senate, bringing down some House Democrats in the process.

Republican leaders are privately telling members that they do not want to be tarred as Republicans who voted with Democrats to maintain the Affordable Care Act. It’s a message they expect to resonate once the bill reaches the Senate.

“We remain committed to the repeal and replacement of Obamacare with policies that actually work,” Senator Mitch McConnell of Kentucky, the Republican leader, said on the Senate floor Wednesday as he urged members to get on board. “Americans are ready for a better way forward after the failure of Obamacare.”

But the flaw in that theory is that plenty of groups that usually support Republicans have already expressed distaste for the repeal-and-replace measure and are urging members to reject it.

“In 2018, members are going to have to campaign for re-election and say, ‘Look we repealed Obamacare,’ and voters are going to look at their premiums and say, ‘Oh no you didn’t,’ ” said Dan Holler, a spokesman for Heritage Action for America, a conservative group. “In the long term, it is not in the best interest of the Republican Party to pass this bill.”

House Republicans could console themselves in thinking that the vote on Thursday could be more like the excruciating vote in 2003 for President George W. Bush’s Medicare prescription drug benefit.

Then, House Republican leaders had to keep the vote open for hours as they twisted arms, finally securing passage, 216-215, over the opposition of the party’s most conservative members, including the current vice president, Mike Pence, an Indiana congressman at the time.

But that measure, which did become law, has proved popular and durable, and the vote — which led to ethics charges against some of the arm-twisters — has largely receded into the history books.