White House Officials, Craving Progress, Push Revised Health Bill

WASHINGTON — White House officials, desperate to demonstrate progress on President Trump’s promise to repeal the Affordable Care Act, are pushing to resurrect a Republican health care bill before his 100th day in office next week.

Some members of the president’s team have grown consumed by that deadline, worrying that appraisals of the president’s tenure will be brutal and hoping that a last push on health care might bring a measure of salvation.

But Congress usually cannot take on two big things at once. At the same moment Mr. Trump hits his 100th day on Saturday, April 29, Republican congressional leaders face a far more urgent deadline: Much of the federal government will run out of money.

Reaching agreement to keep the government open past midnight that Friday will be the first priority of Republican leaders when Congress returns Monday from a two-week recess.

“I believe that when we first go back, that’s going to be the thing we’ll address immediately and have to get done by Friday,” said Representative Dan Donovan, Republican of New York.

The president himself has not laid down a hard deadline on the health care bill. “We have a good chance of getting it soon,” Mr. Trump said in a news conference Thursday. “I’d like to say next week, but it will be — I believe we will get it. And whether it’s next week or shortly thereafter.”

Republican leaders and the White House have been searching for a health care agreement that could placate enough moderates and hard-line conservatives to win passage in the House.

The latest version of the proposal, published Thursday morning by Politico, would maintain popular benefits in President Barack Obama’s signature domestic achievement, like guaranteed coverage for emergency services and maternity care. It would also preserve the health law’s ban on insurers rejecting customers with pre-existing medical conditions.

But under this Affordable Care Act replacement, states could seek waivers from many of those mandates if they demonstrate that premiums would be lowered, the number of insured people would increase, or “the public interest of the state” would be advanced.

States could request an exemption from the rule intended to ensure that people with pre-existing conditions could not be charged prohibitive premiums — but only if those states establish a high-risk insurance pool.

“The plan gets better and better and better, and it’s gotten really, really good, and a lot of people are liking it a lot,” Mr. Trump said. Asked if a health bill could pass as Congress tries to avert a government shutdown, the president said, “I think we’ll get both.”

The complications that remain in the bill are likely to be far too difficult to finesse at the same time the House and Senate press to pass a giant spending bill. Tussles over the spending deadline — including possible debates over top administration priorities like a border wall and money for immigration enforcement officers — are expected to consume the Capitol.

And Democrats — whose votes will be needed to keep the government open — will have their own demands, most importantly billions of dollars to lower out-of-pocket spending for low-income Americans purchasing health coverage on the Affordable Care Act’s online marketplaces.

Senior Republicans appear unconvinced that a revised health care bill would ensure passage in the House. Mr. Donovan, an opponent of the original Republican health care bill, said the proposed amendment “really doesn’t address the concerns that I had.”

Representative Charlie Dent, Republican of Pennsylvania and a leader of the moderate House Tuesday Group, said it “does nothing to change my views.” He lamented any focus “on an arbitrary 100-day deadline.”

The changes — proposed by Representative Tom MacArthur, Republican of New Jersey and co-chairman of the Tuesday Group — come as Republicans face anger from supporters over their failure to act on longstanding campaign pledges, as well as from defenders of the Affordable Care Act.

“We’re in the midst of negotiating sort of finishing touches,” Speaker Paul D. Ryan said this week in London while leading a congressional delegation.

He added: “It’s difficult to do. We’re very close.”

But the legislation’s future is unclear. For now, the proposal exists only in vague talking points. West Wing advisers to Mr. Trump are decidedly mixed in their views of how aggressively to raise expectations. The aide feeling perhaps the most pressure, according to people close to the discussions, is the chief of staff, Reince Priebus, who was blamed internally for the botched vote count around the first repeal effort and is closest to Mr. Ryan within Mr. Trump’s circle.

The initial bill’s failure has left lawmakers wary of artificial deadlines. And even a triumph in the House would not guarantee final passage, given the skepticism of several Republicans in the Senate.

“We want to make sure we replace it with something that will stand the test of time,” Senator Bob Corker, Republican of Tennessee, said in a brief interview Thursday after speaking at a Rotary Club meeting in Crossville, Tenn. “Now we’re taking our time. We realize that this is real — that it’s going to affect people in a real way.”

The House bill’s inability to garner enough support last month to be brought for a floor vote was an embarrassing setback for Mr. Trump, Mr. Ryan and the Republican conference.

This month, Vice President Mike Pence and other Trump administration officials sought a new agreement with the conservative House Freedom Caucus, whose opposition helped fell the first bill. The measure, which gained little traction, earned a nickname on Capitol Hill: Zombie Trumpcare.

Regardless of the bill’s fate, lawmakers are approaching a critical moment on health care. Insurers and business groups are pressing hard for Republicans and Mr. Trump to maintain health insurance subsidies ahead of insurers’ decisions in the coming weeks on whether to keep offerings on the Affordable Care Act’s marketplaces and how much to charge for them.

Without those “cost-sharing reductions,” insurers warn that they will have to sharply raise the prices of their plans on the state marketplaces or leave the markets altogether.

About seven million people now qualify for the subsidies, which reduce the amount someone has to pay in deductibles and co-payments when they buy a plan. At stake is roughly $10 billion in payments expected to be made to the insurers next year. Some House Republicans oppose how the Obama administration funded them, and they won a court case potentially blocking the funding that is now on appeal. The next court date is May 22.

This week, insurance executives met with Medicare officials to plead their case. They left that meeting with Seema Verma, the new Medicare head, with no promises. Mr. Trump has publicly toyed with the idea of withholding the subsidies as a way to force Democrats to negotiate over the House proposal, and Ms. Verma told the insurers they should look to Congress to appropriate the money.

State insurance regulators with the National Association of Insurance Commissioners sent a letter to Congress on Wednesday, pleading, “Your action is critical to the viability and stability of the individual health insurance markets in a significant number of states across the country.”

Insurers must begin the process of filing rates in the coming weeks, and many are looking at various scenarios, said David M. Dillon, a fellow at the Society of Actuaries, who has been working with state regulators and insurers about how to price plans in the marketplace. Insurers say their rates could rise as much as 30 percent, high enough to destabilize the markets.

Insurers remained largely silent on the proposed amendment, which seemed to revive a discussion of how to handle the sickest and most costly individuals by allowing states to set up high-risk pools. The insurers have previously indicated that they would be open to ideas that helped pay for people with very expensive conditions.

Separating off these individuals causes the cost of coverage for everyone else to go down, making it a potentially popular idea, said Stephen Zuckerman, a co-director of the Health Policy Center at the Urban Institute. But these pools have traditionally been poorly funded, leaving many people with potentially expensive pre-existing medical conditions without affordable coverage, if they can buy a plan at all.

“Why would these high-risk pools work better now than they have historically?” Mr. Zuckerman asked.