House Vote to Repeal Affordable Care Act Is Postponed, Despite Trump’s Effort

MARCH 23, 2017

WASHINGTON — House Republican leaders postponed a planned vote Thursday in the full House on legislation to repeal the Affordable Care Act as President Trump and his allies struggled to round up votes amid a tide of defections from the proposed replacement bill.

House Speaker Paul D. Ryan was to address reporters Thursday afternoon, but that too was put off amid signs that legislation — years in the making — to eliminate President Barack Obama’s signature domestic achievement was in deep trouble.

President Trump had agreed to many of the demands that the most conservative House Republicans had made, including ending requirements that health insurance plans provide a basic set of benefits like maternity care, emergency services, mental health and wellness visits.

Sean Spicer, the White House press secretary, announced the change after a late-morning negotiating session that Mr. Trump held at the White House with the Freedom Caucus, the conservative coalition that has strongly disagreed with the measure.

But it was not enough to lock down the group’s votes. Meantime, more centrist House Republicans were peeling away from the bill.

The White House had resisted addressing the regulations as part of the bill set for a House vote on Thursday, arguing that doing so could imperil the bill’s chances in the Senate, but with Republicans revolting against the measure, the concession was a last-ditch effort to win a majority.

“We walked out with more members in support of the American Health Care Act than we started the day with,” Mr. Spicer told reporters. “I anticipate that we will get there.”

After all the negotiations, passage seemed, if anything, farther away. Some rank-and-file members balked at the removal of coverage and benefits their constituents depend on. The president scheduled a late-afternoon meeting at the White House with members of the centrist Tuesday Group.

“We’re certainly trying to get to ‘yes,’” said Representative Mark Meadows, Republican of North Carolina and the chairman of the House Freedom Caucus. “We’ve made very reasonable requests and we’re hopeful that those reasonable requests will be listened to and ultimately agreed to.”

As Mr. Trump pressed to persuade conservatives to support the measure, the changes he has incorporated have alienated some other Republicans who were already nervous about the bill. Those lawmakers have the potential to cost the bill vital support in the Senate.

“There’s a little bit of a balancing act,” Mr. Spicer conceded.

But he defended the removal of the so-called “essential health benefits” regulations, saying it would accomplish Mr. Trump’s stated goal of reducing health care costs.

“Part of the reason that premiums have spiked out of control is because under Obamacare, there were these mandated services that had to be included,” he said.

President Trump appealed to his supporters to weigh in, assuring them, “Go with our plan. It’s going to be terrific.”

But the prospect of a vote on Thursday on a newly revised bill exposed Republicans to criticism that they were moving recklessly in a desperate bid to get their plan passed. Representative Jim McGovern, Democrat of Massachusetts, pleaded with Republicans to slow down.

“This health care repeal affects millions upon millions upon millions of Americans,” he said. “Don’t jam a disastrous bill through the House with patched-up fixes.”

And the changes could prove to be illusory. Under the strict budget rules being used to advance the bill, changes to the Affordable Care Act must have an impact on the federal deficit — positively or negatively. Regulatory measures that have an effect on private health policies would most likely be challenged by Senate Democrats. If the Senate parliamentarian rules in the Democrats’ favor, those hard-fought changes in the House would be stripped from the bill.

The emerging power of the Freedom Caucus, a group that has been historically marginalized in policy-making but a thorn in the side of leadership, is one of the surprises of the rushed health care debate. The Freedom Caucus has been empowered by the addition of one of their own, former Representative Mick Mulvaney, to the senior White House staff as budget director, and Mr. Trump’s disengagement from policy details coupled with his intense desire to score a win after a rocky start to his presidency.

Mr. Trump, Vice President Mike Pence and the House speaker, Paul D. Ryan of Wisconsin, worked on Wednesday to placate conservative House Republicans who said that the bill did not do enough to reduce health insurance costs by cutting federal regulations. The legislation would roll back major provisions of the Affordable Care Act, a pillar of President Barack Obama’s legacy.

But in trying to satisfy conservatives, the Trump administration and House Republican leaders risked jeopardizing support for the bill among more moderate Republicans.

Mr. Obama stepped into the fray on Thursday with a lengthy defense of his signature domestic achievement — and a call for bipartisan improvements.

“I’ve always said we should build on this law, just as Americans of both parties worked to improve Social Security, Medicare, and Medicaid over the years,” he wrote in a mass email to followers on the seventh anniversary of signing the measure into law. “So if Republicans are serious about lowering costs while expanding coverage to those who need it, and if they’re prepared to work with Democrats and objective evaluators in finding solutions that accomplish those goals — that’s something we all should welcome. But we should start from the baseline that any changes will make our health care system better, not worse for hard-working Americans.”

As the crucial vote approached, party leaders appeared to be short of a majority, as moderate Republicans continued to move away from the bill.

Representative Jaime Herrera Beutler, Republican of Washington state, said Thursday that she would oppose the bill. “We can do better than the current House replacement plan,” she said.

And late Wednesday night, Representative Charlie Dent, Republican of Pennsylvania and a leader of the moderate bloc of lawmakers known as the Tuesday Group, said that he would oppose the bill.

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“I believe this bill, in its current form, will lead to the loss of coverage and make insurance unaffordable for too many Americans, particularly for low- to moderate-income and older individuals,” Mr. Dent said. He added that he hoped that the House could “step back from this vote and arbitrary deadline to focus on getting health care reform done right.”

Conservatives were still trying to win changes to make the bill more palatable to them. But the fight over the essential health benefits mandated by the Affordable Care Act has become a serious dividing line.

The Affordable Care Act requires insurers to provide “essential health benefits” in 10 broad categories, including maternity care, mental health care and addiction treatment, preventive services, emergency services and rehabilitative services.

Family planning groups and advocates for women’s rights criticized Republican plans to roll back these requirements.

“Paul Ryan and his House members are willing to sell out the moms of America to pass this bill,” said Dawn Laguens, an executive vice president of the Planned Parenthood Federation of America.

Conservatives say the mandates, as interpreted in rules issued by the Obama administration, add to the costs of health insurance and make it difficult for insurers to offer lower-cost options tailored to the needs of consumers.

Treatment for addiction grew with the Medicaid expansion under Obama’s health care act, but millions may lose coverage if the House approves a measure to repeal the Affordable Care Act.

Seema Verma, the new administrator of the Centers for Medicare and Medicaid Services, has suggested that coverage of maternity care should be optional, not required, as it is now under the Affordable Care Act.

In response to a question at her Senate confirmation hearing last month, Ms. Verma said:

“Some women might want maternity coverage and some women might not want it, might not choose it, might not feel like they need that. So I think it’s up to women to make the decision that works best for them and their families.”

Democrats say that the purpose of insurance is to share risk and that, without federal requirements, insurers would once again offer bare-bones policies. Before the Affordable Care Act took effect, maternity coverage was frequently offered as an optional benefit, or rider, for a hefty additional premium.

Dr. Rebecca B. Parker, president of the American College of Emergency Physicians, said she was alarmed at the possibility that the requirement for essential health benefits might be eliminated.

Without coverage of such services, she said, some patients might be afraid to seek care in an emergency. “We don’t want people clutching their chest and wondering if they should come to the emergency room,” Dr. Parker said.

The tenacity and persistence of the conservatives appeared to give them outsize influence as Mr. Ryan struggled to round up votes for the repeal bill, which faces solid opposition from House Democrats. Supporters of their bill have put their faith in Mr. Trump, whose young presidency could be badly damaged by a public and consequential loss.

“When the president calls someone and says, ‘I need your vote on this,’ it’s very hard to say no to the president of the United States when this torpedoes our entire conference, Trump’s entire presidency, and we end up losing the Senate next year and we lose members in the House,” said Representative Chris Collins, Republican of New York and a top Trump supporter in the House.

A spokeswoman for the Freedom Caucus, Alyssa Farah, said Wednesday that more than 25 members of the caucus were considered “no” votes on the health care measure — enough to sink the bill in the House, though that count could not be independently verified.

Representative Andy Harris, Republican of Maryland, said that despite recent changes to the health care bill, he was unable to vote for it.

“This legislation simply won’t lower premiums as much as the American people need, and lowering the cost of coverage is my primary goal,” said Mr. Harris, an anesthesiologist and Freedom Caucus member.