The clock is running out to repeal Obamacare, and divisions within the GOP are deeper than ever.
Few Republicans are happy with the bill written by House Speaker Paul Ryan and endorsed by President Trump. Called the American Health Care Act, the legislation would repeal key parts of former President Obama’s signature health care law but also keep in place much of its framework.
The bill would cut $880 billion from Medicaid over 10 years and reduce subsidies to low-income Americans. Many moderate Republicans see it as too damaging to the poor.
Conservatives, meanwhile, argue that the bill leaves too much of Obamacare in place, including the insurance subsidies and Medicaid programs, and want to make good on their promise to repeal Obamacare root and branch.
Skepticism about the Republican plan has grown on both sides after the release of a report by the Congressional Budget Office that forecast the law would cause 24 million people to lose insurance coverage by 2026, and insurance premiums would not fall more than 10% by 2026. Now, Republicans are scrambling to make changes to the bill so that it can pass when it comes up for a vote next week, with each faction of the party proposing its own changes.
The big problem for Trump and Ryan is that every change that makes one group of Republicans happy will anger others. Amending the bill is a careful balancing act: go too far to the right, and they'll lose the moderates. Go too far to the middle, and they will lose the conservatives.
Whether the changes are incorporated or not remain to be seen. It is not clear whether the bill can pass the House, and it will face stiff resistance upon its arrival in the Senate.
Below are some of the major changes Republicans of different stripes want to see made to the bill.
Increase help for lower-income people. The current version of the Republican bill proposed by Ryan reduces subsidies for low-income earners and increases subsidies for middle-income earners. That would make insurance on the individual market unaffordable for many, particularly the poor in rural areas who may receive thousands of dollars a year from the federal government to help pay for insurance.
In favor: Moderate Republicans, including Reps. Carlos Curbelo of Florida, Rep. Charlie Dent of Pennsylvania, Rep. Pat Tiberi of Ohio, as well as senators like John Thune of South Dakota are leading a push to send more federal dollars to poor people to help subsidize their insurance plans.
“My goal, and what I’ve been working on the last few days is to target those tax credits more to people who really need the help,” Rep. Curbelo said in an interview. That could include increasing the amount of money the federal government spends to insure poorer people.
The pushback: Many conservatives are opposed to any tax credits at all. Expanding the tax credits would alienate the right wing of the party. "That dog doesn't hunt," Rep. Mark Meadows, chair of the conservative Freedom Caucus, said last month.
Freeze Obamacare’s Medicaid expansion a year earlier. Before Obamacare, Medicaid was offered only to those at the federal poverty line or below — $24,250 for a family of four. But the Affordable Care Act gave states the option to expand Medicaid to 138% of the federal poverty line, granting health insurance to millions of Americans.
The current Republican plan would freeze the Medicaid expansion in 2020, meaning that no new households between 100% and 138% of the poverty line could sign up for help in the states where the program was expanded. That would cause Medicaid to shrink over time: for example, a family that became ineligible one year (by making more than 138% of the federal poverty line) would not be able to sign up again if their income dropped.
In favor: Now some conservatives want to see the program frozen earlier, as soon as 2018. The idea would be to halt the expansion before a presidential election year, when it could become more controversial. Some members of the large Republicans Study Committee say this would be a necessary addition for them to vote for the bill.
The pushback: This is out of the question for many moderates, who like the Medicaid expansion and already strongly oppose freezing it in 2020. “Moving the Medicaid date from 2020 to 2018 is a nonstarter. A complete and total non-starter,” said Dent, co-chair of the moderate Tuesday Group.
Cut more of Obamacare’s insurance regulations. In an effort to improve insurance coverage, Obama’s legislation included a bevy of new regulations for insurance companies. Some of the popular ones included allowing young people to stay on their parents plan until age 26 and prohibiting insurance companies from discriminating on the basis of preexisting conditions.
The less popular ones included stringent requirements on insurance companies about what kind of coverage they had to provide, including preventative services, maternity care and pediatric services. That made some insurance packages better, but also significantly more expensive. And not everyone wanted to buy the same package. Under Obamacare, insurance premiums have continued to rise, often dramatically, a result in part of the regulations.
In favor: The current bill repeals some regulation, but conservatives changes that would allow insurance companies to vary their prices more.
"We need to know what the insurance regs are going to look like," said Rep. David Brat of the House Freedom Caucus. "If you don't now what the regs look like how do you structure the rest of the healthcare plan around that when that's the key cost driver."
The pushback: The Republicans are repealing the bill through a budgetary process known as reconciliation. That way, they won’t need support from Democrats in the Senate.
But only financial matters can be changed through reconciliation. If the conservatives load the bill with regulatory changes, it may not abide by Senate rules. That limits what conservatives can actually do.
Require people receiving Medicaid to work. One area of possible agreement among conservatives and moderates is work requirements for Medicaid. Republicans want to see low-income Medicaid recipients working and ultimately moved off the program. In Montana, for instance, the Medicaid expansion came with an option that recipients met with a labor specialist to help them get a higher-paying job.
In favor: Republicans across the board would be open to seeing it made a requirement in all states, though there is disagreement on how to structure it.
“If you're truly understanding the principle as far as people finding upward mobility, it is to transition off programs not add people to it," said Rep. Mark Walker, chair of the Republican Study Committee.
The pushback: Conservatives want to see mandatory work requirements. Current discussions are around optional work requirements for the states.
Making it optional "doesn't move the ball more than a couple yards on a very long playing field,” said Meadows.
Dismantle all of Obamacare. For some conservatives, arguments over tinkering with the Republican replacement plan are merely academic. They want to see the Affordable Care Act entirely undone, and instead, a competitive healthcare market with little to no federal involvement put in its place.
That would mean expanded health savings accounts, which allow individuals to put money away tax-free to save for health expenses, and also undoing any subsidies to help the poor buy insurance.
In favor: Anything else, say conservatives, doesn’t fly. “For four STRAIGHT elections, REPUBLICANS ran on repealing Obamacare, and now ‘Republican orthodoxy’ — I’m told — is keeping insurance subsidies, mandates, taxes, and insurance company bailouts,” wrote Sen. Rand Paul of Kentucky in an op-ed for Breitbart News. “We need a new way, and Obamacare Lite isn’t it.”
The pushback: Most Republicans oppose an outright repeal of Obamacare without any replacement. Moderates, particularly those in swing states, worry that millions lose health insurance plans.
Turn Medicaid into a block grant. Under the current system, Medicaid is an open-ended commitment by the federal government to cover anyone in the country who qualifies for the program.
But in an effort to make the program more cost-efficient, conservatives have long wanted the federal government to turn Medicaid over to the states, giving each state a limited amount of money each year to support Medicaid recipients. The amount states get each year would grow according to inflation.
In favor: President Trump agreed in a meeting on Friday with conservatives to seek this change to the bill, making many on the right happy.
The pushback: Republican governors and moderates, particularly in states that expanded Medicaid, say this would severely reduce their funding in the long term. Medical costs are rising faster than inflation, and states would have to bear much of the cost.