Ryan Points to Deficit Cut to Seek Support for Health Care Bill - New York Times
Speaker Paul D. Ryan was counting on that deficit reduction — as well as tax cuts for high earners and insurance and medical device companies — to entice members whose Republican constituents want to see the law crumble.
He is facing critics from different factions in his party, including conservatives who say the bill does not represent the wholesale replacement of President Barack Obama’s signature health law that Republicans pledged, and more moderate members concerned that thousands of constituents will lose coverage.
Because Democrats are expected to vote as a bloc against the House bill, Republicans cannot afford many defections when the bill is expected to come to a vote next week.
But by underscoring the bill’s effect on the ranks of the uninsured, Congress’s official scorekeeper, the C.B.O., made wavering Senate Republicans all the more skittish of the House’s legislation. Any of the changes that senators are seeking would almost certainly alienate conservative House Republicans who already believe the bill is too generous.
“The C.B.O. score has modified the dynamics,” said Representative Leonard Lance, Republican of New Jersey. “It’s incumbent upon our leadership in the House to make sure that whatever is being discussed has the ability to pass in the Senate,” Mr. Lance said, “and I do not believe that that is currently the case.”
Mr. Trump was left to strike a balance between siding with House Republicans while also distancing himself from the details, with top aides conceding that the legislation needed modifications before it could pass the full Congress.
On Tuesday, the president talked with House leaders about revisions to address the concerns of the most conservative members, and to Republican senators who fear the measure headed to the House floor would be too costly for older residents.
The C.B.O. report clarified just who stood to lose the most under the Republican plan, which in effect would shift health insurance costs from younger, healthier Americans to older, sicker Americans.
Under current law, insurers cannot charge older adults more than three times what they charge young adults for the same coverage. The House bill would allow insurers to expand that to 5-to-1.
Senator Bill Cassidy, Republican of Louisiana, noted that Americans over 60 who earn a little too much to qualify for Medicaid would “have a hard time affording insurance” under the House plan, since insurance premiums would rise far higher than the modest tax credits on offer. “That’s not good,” he said.
The House bill includes large transition grants to the states that can be used to help cover people with pre-existing medical conditions, subsidize insurance purchases beyond the bill’s tax credits, or other interventions; some Senate Republicans would seek to make those bigger as well. Mr. Thune wants to revise the tax credits so that they would be focused more on lower-income people.
The changes sought by Senate Republicans could upend White House efforts to shore up support from Mr. Ryan’s conservative flank. On Tuesday, several of the most conservative members of the House continued to voice their opposition.
“Leadership’s public positions have pretty much been ‘this is the bill, take it or leave it’ kind of approach,” said Representative Mark Meadows, Republican of North Carolina and chairman of the House Freedom Caucus, adding, “I have no indication that it has changed.”
And if changes are not made, conservatives are balking.
“I’m a no,” Representative Dave Brat, Republican of Virginia, said in an interview on Tuesday. “The C.B.O. report doesn’t really affect my calculation too much.”
Mr. Ryan’s calculus at this point is less strategic (how to actually get a bill that would replace the health care law to final passage) than tactical (how to muster enough votes to get the measure through the chamber he leads).
House Republicans portrayed the intraparty divisions as minor.
“I think what we unite upon is much greater than what divides us in this,” Representative Kevin Brady of Texas, chairman of the Ways and Means Committee, which is responsible for part of the repeal measure, said on Fox News Tuesday.
Mr. Ryan is counting on Mr. Trump, whom he talks to almost daily, to help win passage of the bill in the House. The speaker would then leave it to Senate Republicans to decide if they want to be the ones to refuse to honor the longstanding Republican promise to repeal the law.
Credit
Al Drago/The New York Times
Mr. Trump, though, has remained leery of Mr. Ryan since the campaign, when the speaker publicly voiced skepticism about Mr. Trump. That point was reinforced this week when Breitbart News, a right-wing website and frequent Ryan critic, released comments by Mr. Ryan from October that were critical of Mr. Trump.
And House conservatives continued to oppose the bill, which Representative Mo Brooks, Republican of Alabama, described in an interview with CNN as “still the largest welfare program ever proposed by the Republican Party.”
But the very elements of the bill that conservatives, whose votes will be needed for final House passage, want changed are the very things that many Republican senators, who have a far broader base of constituents, are fighting to maintain or enhance.
That is true even in Republican states where the law has helped many patients, especially those who are too young for Medicare but aging and thus more costly to insure.
“The way to get to yes is to pass legislation that honors our promise to repeal Obamacare and that drives down costs,” said Senator Ted Cruz, Republican of Texas, arguing that the House bill did not do enough to drive down insurance premiums.
Mr. Ryan was also not getting any support from Republican governors, who are trying to figure how they can roll back Medicaid expansion without leaving poor and older residents uninsured.
“Their bill needs to be the starting point, not the ending one,” Gov. Asa Hutchinson of Arkansas, a Republican, said in an interview.
There is additional pressure on Republicans from groups like AARP, the lobby for older Americans that is fighting provisions of the House bill that could significantly increase health insurance premiums for older Americans.
“The bill will dramatically increase health care costs for 50-to-64-year-olds who purchase health care through an exchange,” said Joyce A. Rogers, a senior vice president of AARP, who denounced the plan as an “age tax.”
Hospitals, with billions of dollars at stake, also stepped up lobbying against the House bill.
A coalition of health care providers and advocates, the Alliance for Healthcare Security, is running television advertisements describing the harm that it says could come from curtailing the expansion of Medicaid. The ads are running in Alaska, Arizona, Maine, Nevada and West Virginia and are meant to influence senators from those states.
“Tell your senator, these Medicaid cuts hurt real people,” one advertisement says.
Susan Van Meter, a senior vice president of the Healthcare Association of New York State, recently led a delegation of hospital executives in a lobbying trip to Capitol Hill.
The proposed changes in Medicaid, she said, “are, by far, the most worrisome provisions of the bill, would be disastrous for patients and could create a fiscal crisis for New York.”
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