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| Republicans Struggle to Marshal Votes for Health Care Bill | Republicans Struggle to Marshal Votes for Health Care Bill |
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| WASHINGTON — Republican leaders scrambled for support on Tuesday ahead of a vote to take up legislation repealing the Affordable Care Act, negotiating, pressuring and cajoling Republican senators but preparing for another embarrassing setback for President Trump. | WASHINGTON — Republican leaders scrambled for support on Tuesday ahead of a vote to take up legislation repealing the Affordable Care Act, negotiating, pressuring and cajoling Republican senators but preparing for another embarrassing setback for President Trump. |
| Republican leaders seemed to be taking a page from the playbook used to get a bill over the line in the House, trying to find ways to appease the most conservative members of their conference while pressuring moderates to fall in line with fewer concessions. Senator Mitch McConnell of Kentucky, the majority leader, cast his lot early on by allowing the bill to be more conservative than his moderate members wanted, setting the tone for the debate. | Republican leaders seemed to be taking a page from the playbook used to get a bill over the line in the House, trying to find ways to appease the most conservative members of their conference while pressuring moderates to fall in line with fewer concessions. Senator Mitch McConnell of Kentucky, the majority leader, cast his lot early on by allowing the bill to be more conservative than his moderate members wanted, setting the tone for the debate. |
| Conservatives now want to allow states to waive the Affordable Care Act’s prohibition on insurance companies charging sick people more for coverage and are asking for a more expansive waiver system for state regulators. They are also demanding more money for tax-free health savings accounts to help people pay for private insurance. | Conservatives now want to allow states to waive the Affordable Care Act’s prohibition on insurance companies charging sick people more for coverage and are asking for a more expansive waiver system for state regulators. They are also demanding more money for tax-free health savings accounts to help people pay for private insurance. |
| Senators from states that expanded the Medicaid program — and Senator Susan Collins, Republican of Maine — would most likely not brook many of those changes, especially the measure to severely undermine protections for people with pre-existing medical conditions. They want more money for mental health benefits for people addicted to opioids and money for states to cover people left behind by the rollback of the Medicaid program in both the House and Senate versions. | Senators from states that expanded the Medicaid program — and Senator Susan Collins, Republican of Maine — would most likely not brook many of those changes, especially the measure to severely undermine protections for people with pre-existing medical conditions. They want more money for mental health benefits for people addicted to opioids and money for states to cover people left behind by the rollback of the Medicaid program in both the House and Senate versions. |
| On Monday, three Republican senators — Ms. Collins, Rand Paul of Kentucky and Ron Johnson of Wisconsin — said they would vote against the motion to begin debate scheduled to hit the Senate floor on Wednesday, joining Senator Dean Heller of Nevada, who made the same pledge on Friday. | On Monday, three Republican senators — Ms. Collins, Rand Paul of Kentucky and Ron Johnson of Wisconsin — said they would vote against the motion to begin debate scheduled to hit the Senate floor on Wednesday, joining Senator Dean Heller of Nevada, who made the same pledge on Friday. |
| A bevy of other senators from both flanks of the party seemed headed in the same direction if they did not see changes made to the Senate health care bill, leaving the measure in deep peril, since Republicans can only lose two votes from their own party. | A bevy of other senators from both flanks of the party seemed headed in the same direction if they did not see changes made to the Senate health care bill, leaving the measure in deep peril, since Republicans can only lose two votes from their own party. |
| But House Speaker Paul D. Ryan, who won House approval for a repeal bill after a few false starts, expressed confidence in Mr. McConnell on Tuesday. | |
| “I would not bet against Mitch McConnell,” Mr. Ryan said. “He is very, very good at getting things done through the Senate, even with this razor-thin majority. I have every expectation that the Senate — I don’t know what day — but I have every expectation the Senate will move this bill.” | “I would not bet against Mitch McConnell,” Mr. Ryan said. “He is very, very good at getting things done through the Senate, even with this razor-thin majority. I have every expectation that the Senate — I don’t know what day — but I have every expectation the Senate will move this bill.” |
| The release of a Congressional Budget Office evaluation on Monday did little to help leaders roll up votes from either side of the fence. The budget office said the Senate bill would leave 22 million more uninsured after 10 years, while sending out-of-pocket medical expenses skyrocketing for the working poor and those nearing retirement. | The release of a Congressional Budget Office evaluation on Monday did little to help leaders roll up votes from either side of the fence. The budget office said the Senate bill would leave 22 million more uninsured after 10 years, while sending out-of-pocket medical expenses skyrocketing for the working poor and those nearing retirement. |
| The budget office did not provide conservatives with support for their demands either. The state waivers already in the Senate bill “would probably cause market instability in some areas” and “would have little effect on the number of people insured” by 2026, the analysis concluded. Adding still more waivers, including one that could allow insurers to price the sick out of the health care market, could deprive even more people of health care. | The budget office did not provide conservatives with support for their demands either. The state waivers already in the Senate bill “would probably cause market instability in some areas” and “would have little effect on the number of people insured” by 2026, the analysis concluded. Adding still more waivers, including one that could allow insurers to price the sick out of the health care market, could deprive even more people of health care. |
| White House officials were bracing for the increasing likelihood that the procedural vote would fail and they would have to take the measure back up after the Fourth of July recess — when they hoped to be able to woo Mr. Johnson, who has been a surprisingly fierce critic of the bill from the right. The senator has repeatedly warned that this week is too soon to vote on the health care measure, as Republican senate leaders have insisted they need to do. | White House officials were bracing for the increasing likelihood that the procedural vote would fail and they would have to take the measure back up after the Fourth of July recess — when they hoped to be able to woo Mr. Johnson, who has been a surprisingly fierce critic of the bill from the right. The senator has repeatedly warned that this week is too soon to vote on the health care measure, as Republican senate leaders have insisted they need to do. |
| Just as he did with the House when the far right and a small group of moderates both prevented initial passage of a bill, Vice President Mike Pence, who has attended most of the Senate Republican Tuesday lunches — and quietly hosted senators and House members for a weekly dinner at his Naval Observatory residence — has been playing a prominent role this week in trying to whip up votes. | Just as he did with the House when the far right and a small group of moderates both prevented initial passage of a bill, Vice President Mike Pence, who has attended most of the Senate Republican Tuesday lunches — and quietly hosted senators and House members for a weekly dinner at his Naval Observatory residence — has been playing a prominent role this week in trying to whip up votes. |
| On Tuesday, he will attend the Senate Republican lunch once again and then break off for private meetings with Mr. Heller, a seemingly firm “no” and the first moderate Republican to break with Mr. McConnell over the bill, and Rob Portman of Ohio, who is feeling pressure from his state’s governor, John R. Kasich, to oppose the bill and defend Ohio’s Medicaid expansion. | On Tuesday, he will attend the Senate Republican lunch once again and then break off for private meetings with Mr. Heller, a seemingly firm “no” and the first moderate Republican to break with Mr. McConnell over the bill, and Rob Portman of Ohio, who is feeling pressure from his state’s governor, John R. Kasich, to oppose the bill and defend Ohio’s Medicaid expansion. |
| Mr. Portman was the subject of a spirited evaluation of his open criticism of the bill by Mr. McConnell, who has been frustrated with the expansion-state senators who have shown their hand early to other wavering colleagues, perhaps dooming the bill. Mr. McConnell was unhappy that Mr. Portman seemed to be abandoning his previous stance on fiscal rectitude by opposing Medicaid cuts in the bill. | Mr. Portman was the subject of a spirited evaluation of his open criticism of the bill by Mr. McConnell, who has been frustrated with the expansion-state senators who have shown their hand early to other wavering colleagues, perhaps dooming the bill. Mr. McConnell was unhappy that Mr. Portman seemed to be abandoning his previous stance on fiscal rectitude by opposing Medicaid cuts in the bill. |
| But the Ohio senator is getting it from both sides. Mr. Kasich appeared in Washington Tuesday to sharply criticize the Senate bill. The governor said he was deeply concerned about millions of people losing coverage under the bill. | |
| “Who would lose this coverage?” Mr. Kasich said. “The mentally ill, the drug addicted, the chronically ill. I believe these are people that need to have coverage.” | |
| At the same news conference, Colorado’s Democratic governor, John Hickenlooper, said his state’s Republican senator, Cory Gardner, “understands the hardships and the difficulties in rural life.” | |
| “This bill would punish people in rural Colorado,” Mr. Hickenlooper said, raising the pressure. | |
| Mr. Pence is likely to add other senators to his must-see list, and he plans to host a health care-related dinner at his house Tuesday night, with Mike Lee of Utah, Tom Cotton of Arkansas, Ben Sasse of Nebraska and James Lankford of Oklahoma, according to a senior administration official. Mr. Sasse has been an understated but strong opponent of the bill as written. | Mr. Pence is likely to add other senators to his must-see list, and he plans to host a health care-related dinner at his house Tuesday night, with Mike Lee of Utah, Tom Cotton of Arkansas, Ben Sasse of Nebraska and James Lankford of Oklahoma, according to a senior administration official. Mr. Sasse has been an understated but strong opponent of the bill as written. |
| President Trump — who praised the House-passed bill effusively only to then call it “mean” — has been playing a far less central role in the knife-edge effort to salvage the bill, according to several administration officials involved in the process. | President Trump — who praised the House-passed bill effusively only to then call it “mean” — has been playing a far less central role in the knife-edge effort to salvage the bill, according to several administration officials involved in the process. |
| His dial-a-senator dance card has been relatively light: Mr. Trump spoke with Ted Cruz of Texas, his main rival for the 2016 nomination, over the weekend, as well as Mr. Lee and one or two others, but the pace was nothing like the dozens of calls he made to push the House bill over the line, aides said. | His dial-a-senator dance card has been relatively light: Mr. Trump spoke with Ted Cruz of Texas, his main rival for the 2016 nomination, over the weekend, as well as Mr. Lee and one or two others, but the pace was nothing like the dozens of calls he made to push the House bill over the line, aides said. |
| The environment for Mr. Trump in the Senate is far less hospitable than in the House, and several Republicans who remain on the fence or opposed to the bill — including Mr. Paul and Marco Rubio of Florida — are failed presidential candidates who were the targets of Mr. Trump’s bruising insults during the campaign. | The environment for Mr. Trump in the Senate is far less hospitable than in the House, and several Republicans who remain on the fence or opposed to the bill — including Mr. Paul and Marco Rubio of Florida — are failed presidential candidates who were the targets of Mr. Trump’s bruising insults during the campaign. |
| With Mr. Trump playing a supporting role at the moment, Mr. Pence’s team is the tip of the spear on the lobbying effort. Top Trump lieutenants like Stephen K. Bannon, his chief strategist, who lobbied members on the House bill, are all-but sidelined. The White House chief of staff, Reince Priebus, who is not highly regarded in the Senate, has also played a much diminished role. | With Mr. Trump playing a supporting role at the moment, Mr. Pence’s team is the tip of the spear on the lobbying effort. Top Trump lieutenants like Stephen K. Bannon, his chief strategist, who lobbied members on the House bill, are all-but sidelined. The White House chief of staff, Reince Priebus, who is not highly regarded in the Senate, has also played a much diminished role. |
| Mr. Pence’s team is taking the lead. Seema Verma, Mr. Pence’s former adviser in the Indiana Statehouse and now a top administration health care official, has been trying to reassure senators that their states will have flexibility on Medicaid under the bill — and Mr. Pence’s former chief of staff, Marc Short, now the White House legislative affairs director, has been quarterbacking the effort from his hideaway in the Capitol. | Mr. Pence’s team is taking the lead. Seema Verma, Mr. Pence’s former adviser in the Indiana Statehouse and now a top administration health care official, has been trying to reassure senators that their states will have flexibility on Medicaid under the bill — and Mr. Pence’s former chief of staff, Marc Short, now the White House legislative affairs director, has been quarterbacking the effort from his hideaway in the Capitol. |
| Doctors, hospitals and other health care provider groups have come out strongly against the Senate bill, as have patient advocacy groups like the American Heart Association. But business groups are ramping up their support. In a letter on Tuesday, the United States Chamber of Commerce endorsed the Senate bill and urged senators to vote for it. | |
| The Senate bill “will repeal the most egregious taxes and mandates” of the Affordable Care Act, allowing employers to create more jobs, said Jack Howard, a senior vice president of the group. The bill, he noted, would repeal a tax on medical devices and eliminate penalties on large employers that do not offer coverage to employees. | |
| A separate letter expressing general support for the Senate’s efforts was sent by a coalition of 28 business and employer groups including the National Association of Home Builders, the National Restaurant Association and the National Retail Federation. | A separate letter expressing general support for the Senate’s efforts was sent by a coalition of 28 business and employer groups including the National Association of Home Builders, the National Restaurant Association and the National Retail Federation. |
| Even the Trump administration is divided over what comes next, especially on the payment of subsidies to health insurance companies to compensate for reducing out-of-pocket costs for low-income people. | Even the Trump administration is divided over what comes next, especially on the payment of subsidies to health insurance companies to compensate for reducing out-of-pocket costs for low-income people. |
| Mr. Trump has threatened to withhold the monthly payments as a way to induce Democrats to bargain with him over the future of the Affordable Care Act. Administration officials said Mr. Trump did not want to make the payments if the Senate did not pass a health care bill this week. But they said Tom Price, the secretary of health and human services, had urged the White House not to cut off the payments abruptly. | Mr. Trump has threatened to withhold the monthly payments as a way to induce Democrats to bargain with him over the future of the Affordable Care Act. Administration officials said Mr. Trump did not want to make the payments if the Senate did not pass a health care bill this week. But they said Tom Price, the secretary of health and human services, had urged the White House not to cut off the payments abruptly. |
| A federal judge has ruled that the payments are illegal because Congress never appropriated money for them, but that ruling is being appealed. Any interruption of the payments could have a dire destabilizing effect on markets, insurers say. Blue Cross Blue Shield of North Carolina recently blamed the Trump administration’s mixed signals on the subsidy for most of its proposed 23 percent spike in premiums next year. | |
| Sean Spicer, the White House press secretary, defended the administration’s position at his briefing on Friday. | Sean Spicer, the White House press secretary, defended the administration’s position at his briefing on Friday. |
| “If the president were to hypothetically say that he’s going to make the payments in perpetuity or for a year, I think that continues to prop up a failed system,” Mr. Spicer said. “It continues to do wrong by the American taxpayer. And it also doesn’t lend itself to the expediency that I think we want to — help get a new health care system in place.” | “If the president were to hypothetically say that he’s going to make the payments in perpetuity or for a year, I think that continues to prop up a failed system,” Mr. Spicer said. “It continues to do wrong by the American taxpayer. And it also doesn’t lend itself to the expediency that I think we want to — help get a new health care system in place.” |