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.Continue reading the main story
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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.
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.