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House Vote to Repeal Affordable Care Act Is Postponed, Despite Trump’s Effort Trump Tells G.O.P. to Fall in Line, Demanding House Vote on Health Overhaul
(about 5 hours later)
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. WASHINGTON — President Trump issued an ultimatum on Thursday to recalcitrant Republicans to fall in line behind a broad health insurance overhaul or see their opportunity to repeal the Affordable Care Act vanish, demanding a vote on a bill that appeared to lack a majority to pass.
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. The demand, issued by his budget director, Mick Mulvaney, in an evening meeting with House Republicans, came after a marathon day of negotiating at the White House and in the Capitol in which Mr. Trump — who has boasted of his deal-making prowess — fell short of selling members of his own party on the health plan.
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. The initial House vote, called Thursday to coincide with the seventh anniversary of the Affordable Care Act’s signing, had to be postponed, and Mr. Trump confronted the possibility of a humiliating loss on the first significant legislative push of his presidency.
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. At a White House meeting with members of the hard-line conservative Freedom Caucus, he agreed to the conservatives’ demands to strip federal health insurance requirements for basic benefits such as maternity care, emergency services, mental health and wellness visits from the bill. But that was not enough to placate the faction, and a vote scheduled for Thursday was placed on hold.
But it was not enough to lock down the group’s votes. Meantime, more centrist House Republicans were peeling away from the bill. As House leaders struggled to negotiate with holdouts in the hopes of rescheduling a vote as early as Friday, Mr. Trump dispatched senior officials to the Capitol with a blunt message: He would agree to no additional changes, and Republicans must either support the bill or resign themselves to leaving President Barack Obama’s signature domestic achievement in place.
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 have a great bill, and I think we have a good chance, but it’s only politics,” Mr. Trump said earlier Thursday at the White House, as it was becoming clear that his negotiating efforts had failed to persuade enough members of his party to back the plan — which was years in the making — to repeal and replace the health law.
“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.” Privately, White House officials conceded that competing Republican factions were each demanding changes that could doom the effort, placing the measure in peril and Mr. Trump’s chances of succeeding at a high-stakes legislative deal in jeopardy. With some of its demands in place, the Freedom Caucus ratcheted up its requests, insisting on a repeal of all regulatory mandates in the Affordable Care Act, including the prohibition on excluding coverage for pre-existing medical conditions and lifetime coverage caps.
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. Mr. Trump, who has touted his own negotiating skills and invited the label “the closer” as the vote approached, was receiving a painful reality check about the difficulty of governing, even with his own party in power on Capitol Hill.
“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.” “Guys, we’ve got one shot here,” he told members of the Freedom Caucus at a meeting in the Cabinet Room, according to a person present in the room who spoke on the condition of anonymity because the meeting was private. “This is it — we’re voting now.”
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. They were unconvinced.
Having secured Mr. Trump’s acquiescence to eliminate the requirement that insurers offer “essential health benefits,” members of the Freedom Caucus pressed their advantage. While they did not specify precisely which regulations they wanted to eliminate, the section they wanted to gut requires coverage for pre-existing health conditions, allows individuals to remain on their parents’ health care plans up to age 26, bars insurers from setting different rates for men and women, prohibits annual or lifetime limits on benefits, and requires insurers to spend at least 80 percent of premium revenue on medical care.
“We’re committed to stay here until we get it done,” said Representative Mark Meadows, Republican of North Carolina and the chairman of the Freedom Caucus. “So whether the vote is tonight, tomorrow or five days from here, the president will get a victory.”
He said 30 to 40 Republicans planned to vote “no”; House leaders can afford to lose only 22 in order to pass the bill.
But for every concession Mr. Trump made to appease critics on the right, he lost potential rank-and-file supporters in the middle, including members of the centrist Tuesday Group who had balked at the bill’s Medicaid cuts and slashed insurance benefits. Moderate Republicans in that group went to the White House Thursday but emerge unmoved in their opposition.
“We can do better than the current House replacement plan,” Representative Jaime Herrera Beutler, Republican of Washington State, said on Thursday as she said she would oppose the bill.
At the same time, a new estimate of the bill’s cost and its impact on health coverage further soured the picture for wavering lawmakers. The nonpartisan Congressional Budget Office on Thursday issued a report on the revised version of the health care bill showing that it would cost more than the original version but would not cover more people. The report said the bill, like the original version, would result in 24 million fewer Americans having health insurance in 2026 than under current law.
But recent changes to the bill, made through a series of amendments introduced on Monday, would cut its deficit savings in half. Instead of reducing the deficit by $337 billion, the new version of the bill would save only $150 billion over the decade.
The budget office did not consider the effects of various additional changes that remain under negotiation, including the elimination of benefit requirements and other health insurance regulations.
A Quinnipiac University national poll found that voters disapproved of the Republican plan by lopsided margins, with 56 percent opposed, 17 percent supportive and 26 percent undecided. The measure did not even draw support among a majority of Republicans; 41 percent approved, while 24 percent were opposed.
As Mr. Trump pressed to persuade conservatives to support the measure, the changes he promised 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.“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. But he defended the removal of the “essential health benefits” regulations, saying that 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. “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,” Mr. Spicer said.
President Trump appealed to his supporters to weigh in, assuring them, “Go with our plan. It’s going to be terrific.” President Trump appealed to his supporters to weigh in, assuring them in a video posted on Twitter, “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. 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 Raúl Labrador, Republican of Idaho and a member of the Freedom Caucus, said the party’s leaders had tried to ram through the measure over their members’ objections. He panned what he described as a “brute force” strategy that resembled the approach of former Speaker John A. Boehner, Republican of Ohio.
“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.” “It’s better to get it right than to get it fast,” Mr. Labrador said.
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. It was not clear that the changes that Mr. Trump has agreed to and those being demanded could survive. Under the strict budget rules being used to advance the bill, changes to the Affordable Care Act must affect the federal deficit — positively or negatively. Regulatory measures that affect private health policies, not government programs like Medicaid, are highly likely to 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. 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 group has been empowered by the addition of Mr. 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. Mr. Obama stepped into the fray on Thursday with a lengthy defense of his law on the seventh anniversary of its signing, and a call for bipartisan improvements.
But in trying to satisfy conservatives, the Trump administration and House Republican leaders risked jeopardizing support for the bill among more moderate Republicans. “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. “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.”
Mr. Obama stepped into the fray on Thursday with a lengthy defense of his signature domestic achievement — and a call for bipartisan improvements. The Affordable Care Act requires insurers to provide “essential health benefits” in 10 broad categories, including maternity care, mental health care, addiction treatment, preventive services, emergency services and rehabilitative services.
“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.
“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.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.“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. 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 consumers’ needs.
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. 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.
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.