WASHINGTON — Shortly after President Trump took office, Senator Mitch McConnell
of Kentucky, the majority leader, met privately with his colleagues to
discuss the Republican agenda. Repealing the Affordable Care Act was at
the top, he said. But replacing it would be really hard.
Mr. McConnell was right.
The
many meetings Republicans held to discuss a Senate health care bill
have exposed deep fissures within the party that are almost as large as
the differences between Republicans and Democrats. Elements of a bill that passed the House this month have divided Republicans.
Mr.
McConnell faces an increasingly onerous math problem. He can afford to
lose only two Republicans if he is to get a bill through the Senate, and
that would require the help of Vice President Mike Pence, who would
have to cast the tiebreaking vote. But at least three senators in the
party are diametrically opposed to the views of at least another three,
so the path to agreement is narrow.
Republicans are roughly split over whether the expansion of Medicaid
under the Affordable Care Act should be rolled back or continued, at
least in the short run. They disagree about how the federal government
should grant states more control over setting insurance standards. They
are also divided over a critical portion of the House bill, which would
allow states to obtain waivers from two of the most important federal
mandates: a requirement to provide a minimum set of health benefits and a
prohibition against charging higher prices to people with pre-existing
medical conditions.
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The
challenges facing Senate Republicans are so great that overhauling the
tax code is starting to look easier by comparison. “I allow that’s a
possibility,” said Senator Pat Toomey, Republican of Pennsylvania, who
is closely involved in negotiating both issues and favors a rollback of
the Medicaid program.
This
week, the normally circumspect Mr. McConnell conceded that it was going
to be difficult to get the votes needed from Republicans to pass a
health care bill. A Congressional Budget Office report on the House
bill, forecasting an increase
of 23 million Americans without insurance in a decade and significantly
higher premiums for older and sick people, bolstered the resolve of
Republican senators who have been skeptical of the House effort.
Most
Republicans in Congress would like to keep their vow to repeal and
replace the Affordable Care Act, but they face a more urgent challenge:
to stabilize insurance markets that, in some states, are in danger of
melting down next year.
Fact Check: The Updated G.O.P. Health Care Bill
Does the health care bill passed by the House live up to Republicans’ promises? We checked the facts.
By DAVE HORN, NATALIE RENEAU and MARK SCHEFFLER on
Publish Date May 25, 2017.
Photo by Stephen Crowley/The New York Times.
Watch in Times Video »
Every
week brings word of insurers seeking big rate increases or announcing
plans to pull out of another market in 2018. It is conceivable that the
two parties could work together on short-term fixes outside the repeal
process at some point.
“I
don’t think we want the market to fail,” said Senator Orrin G. Hatch,
Republican of Utah and chairman of the Finance Committee, which is
responsible for tax legislation and much of the Affordable Care Act. “We
don’t want premiums to be so high that people can’t afford them.”
Republicans
could pass a repeal measure and return to the health care system that
was largely in place before the Affordable Care Act became law. But
Speaker Paul D. Ryan, among others, has repeatedly stated that his party
has a plan to make the system better, which would require the
replacement part of the repeal-replace equation.
With
health care negotiations sputtering, many Republicans are quietly
turning their attention to changes in the tax code as a possible path
for legislative success. Generally, Republicans are more unified around
the fundamentals of a tax overhaul than on the details of health policy.
The White House team working on tax issues is far less ideological than
the team directing health care efforts, and it has worked harder to
build early momentum, Republicans aides say.
Though Republicans have been calling for a repeal of the health care law
almost since President Barack Obama signed it in 2010, those calls have
become more urgent as some of the insurance exchanges have struggled.
But
with millions of Americans newly insured under the law, many governors,
including some Republicans, are loath to roll it back, and many
senators agree. Twenty Republican senators come from states that have
expanded Medicaid under the Affordable Care Act.
The
House bill, starting in 2020, would sharply reduce federal payments to
states to cover those who became eligible for Medicaid as a result of
the Affordable Care Act.
The
law also has provisions to help drug addicts, and the opioid crisis
sweeping many states with Republican senators has been a key motivator.
“The
opioid issue definitely plays a role,” said Senator Susan Collins,
Republican of Maine. “A lot of the young population that is being
insured under Medicaid has problems with substance abuse or mental illness.”
While
fixing the nation’s tax code has long been considered even harder than
passing health care legislation on Capitol Hill, the opposite could end
up being the case.
Treasury
Secretary Steven Mnuchin and Gary D. Cohn, the director of the
president’s National Economic Council, have held numerous meetings with
lawmakers — including Democrats — on the matter and have attended
several hearings against the backdrop of the contentious health care
talks.
“Taxes has more consensus with Republicans and some Democrats,” said Senator Rob Portman, Republican of Ohio.
Republican
senators have been watching closely as House Republicans have twisted
themselves in knots over the tax “blueprint” that they released last
summer. Many lobbyists and tax experts are hoping that the Senate
emerges as a voice of reason.
Republican
senators continued free-flowing conversations among themselves this
week to analyze their options and search for consensus on a health care
bill that they said would be significantly different from the one passed
by the House.
Senator
John Cornyn of Texas, the majority whip, and Senator Ron Johnson of
Wisconsin said they expected staff experts to draft legislative language
for Republicans to consider when the Senate returns from a weeklong
recess on June 5.
“We’re
talking about this nonstop between ourselves,” Mr. Johnson said of the
Republicans. “It’s an appropriate time now to have leadership and
committee staff, working with leadership and committee chairmen, sit
down and draft a bill, a proposal, for discussion.”
If
the Senate decided not to vote on a health care bill, it would be
likely to enrage the White House, as it did when Mr. Ryan at first
failed to produce a bill that could pass. However, Mr. Trump has
considerably less leverage with Mr. McConnell than he did over House
leaders, as Mr. McConnell and Republican senators are less susceptible
to pressure from the White House.
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